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EMQS and Data Interpretation Questions in Surgery
EMQS and Data Interpretation Questions in Surgery
Interpretation
Questions in
SURGERY
SURGERY
Hodder Arnold
www.hoddereducation.com
Sara Purdy
Jane Tod
Andre Sim
Laura de Grasse
Lisa Footit
Typeset in 9.5/12 RotisSerif by Charon Tec Ltd (A Macmillan Company), Chennai, India
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Dedication
To Mum and Dad for their continuing support.
Irfan Syed
Contents
Contributors
Preface
Acknowledgements
The Plate section appears between pages 212 and 213
SECTION 1: EMQS IN GENERAL SURGERY
Questions
1
Abdominal pain (i)
2
Abdominal pain (ii)
3
Small bowel obstruction
4
Abdominal masses
5
Anorectal conditions
6
Management of colorectal cancer
7
Management of inflammatory bowel disease
8
Investigation of gastrointestinal bleeding
9
Paediatric surgery
10
Splenomegaly
11
Ulcers
12
Abnormal abdominal x-rays
13
Complication of gallstones
14
Breast conditions
15
Treatment of breast cancer
16
Skin lesions
17
Presentation with a lump
18
Pathology terminology
19
Thyroid conditions (i)
20
Thyroid conditions (ii)
21
Feeding the surgical patient
22
The shocked surgical patient
23
Chest trauma
24
Glasgow Coma Scale
25
Complications of blood transfusion
26
Head injury
Answers
SECTION 2: EMQS IN ORTHOPAEDIC SURGERY
Questions
27
Hand conditions
28
Arthritis
29
Joint pain
30
Pain in the hip
31
Back pain
32
Complications of fractures
33
Management of fractures
34
Fall on the outstretched hand
35
Shoulder conditions
36
Knee conditions
37
Management of painful joints
38
Foot conditions
x
xi
xii
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
61
62
63
64
65
66
67
68
69
70
71
72
73
Contents vii
39
Lower limb nerve lesion
40
Upper limb nerve injury (i)
41
Upper limb nerve injury (ii)
Answers
74
75
76
77
93
94
95
96
97
98
103
127
149
Questions
63
Red eye
64
Diseases causing cataracts
65
Neuro-ophthalmology: pupils
66
Neuro-ophthalmology: visual fields
67
Ocular pharmacology
68
Ocular motility and ptosis
69
Ocular and orbital pathology
150
151
152
153
154
155
156
104
105
106
107
108
109
110
111
112
113
128
129
130
131
132
133
134
135
136
viii Contents
70 Retinal pathology
71
Optic nerve pathology
72 Inherited eye disease
Answers
157
158
159
160
170
192
Questions
82 Assessment of burns
83 Complications of burns
84 Skin cover
Answers
193
194
195
196
171
172
173
174
175
176
177
178
179
180
201
202
203
204
205
206
207
208
209
211
212
213
214
215
216
217
218
219
220
221
223
224
225
Contents ix
107
Electrolytes
108 Lung function
Answers
226
227
228
246
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
Index
283
Contributors
Mr Obiekezie Agu MS FRCS(Gen)
Consultant Vascular Surgeon, University College Hospital, London, UK
Miss Sarvi Banisadr BSc(Hons) MBBS MRCS
Specialist Registrar General Surgery, Royal Marsden Hospital, London, UK
Mr Andrew Bath BMedSci BMBS FRCS(ORL)
Consultant ENT Surgeon, Norfolk and Norwich University Hospital, UK
Dr Brigitta Brandner FRCA MD
Consultant Anaesthetist, University College Hospital, London, UK
Mr Raymond Brown MA MBChir FRCS FRCOphth
Consultant Ophthalmologist, University Hospital of North Staffordshire, UK
Mr Fares Haddad BSc MCh(Orth) FRCS(Orth)
Consultant Orthopaedic Surgeon and Honorary Senior Lecturer, University
College London Hospitals, UK
Mr Naveed Jallali BSc MBChB(Hons) MRCS
Specialist Registrar, Plastic and Reconstructive Surgery, Royal Free Hospital,
London, UK
Mr Rohan Nauth-Misir BSc FRCS(Urol)
Consultant Urologist and Clinical Director Urology, University College Hospital,
London, UK
Miss Reshma Syed MBBS MRCS(Ophth)
Specialist Registrar Ophthalmology, University Hospital of North
Staffordshire, UK
Mr Zishan Syed BA
Medical Student, University of Cambridge, Cambridge, UK
Mr Peter Tassone MBChB MRCS
Specialist Registrar, ENT surgery, Norfolk and Norwich University Hospital, UK
Preface
EMQs and Data Interpretation Questions in Surgery has two main roles. First, we
aim to provide a bank of questions for examination practice, as familiarity
breeds confidence. The EMQ revision boxes in EMQs in Clinical Medicine
(Hodder Arnold: 2004) have been popular and so we have included a separate
revision boxes section for easy reference.
Second, we wanted to provide an informative text with detailed explanations,
taking advantage of the collective knowledge from our colleagues in the surgical
specialties.
We sincerely hope that this book helps you in the build-up to your examination
and wish you all the best in your medical career!
Irfan Syed and Mohammed Keshtgar
Acknowledgements
This book would not have been possible without the excellent work in reviewing,
writing and editing questions by our colleagues.
Many thanks also to Jane, Sara, Amy and the Hodder Arnold team for their
efforts in bringing this project to fruition.
SECTION 1: EMQS IN
GENERAL SURGERY
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
QUESTIONS
1 Abdominal pain (i)
A
B
C
D
E
F
G
H
I
J
K
L
M
aortic dissection
diverticulosis
duodenal ulcer
renal colic
colorectal carcinoma
mesenteric adenitis
For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.
1
A 28-year-old man presents with sharp left loin and left upper quadrant pain
radiating to the groin. He is not jaundiced.
A 44-year-old woman presents with continuous right upper quadrant pain, vomiting and fever. There is marked right upper quadrant tenderness when palpating on
inspiration.
A 50-year-old man with a history of epigastric pain presents with constant severe
generalized abdominal pain. On examination he is distressed and has a rigid
abdomen. Pulse is 110/min, BP 100/60 mmHg.
hepatitis
irritable bowel syndrome
umbilical hernia
primary sclerosing cholangitis
perforated duodenal ulcer
small bowel obstruction
ulcerative colitis
H
I
J
K
L
M
Crohns disease
carcinoma of caecum
acute appendicitis
gastric ulcer
hepatocellular carcinoma
diverticulitis
For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.
1
A 9-year-old girl presents with fever, nausea and right iliac fossa pain. She says
that the pain was around my belly button before.
A 35-year-old man presents with weight loss, diarrhoea and abdominal pain. On
examination he has aphthous ulcers in the mouth and a mass is palpable in the
right iliac fossa. Blood tests reveal low serum B12 and folate.
A 72-year-old man with a history of constipation presents with increased temperature, diarrhoea and left iliac fossa pain. On examination there is tenderness in the
left iliac fossa.
adhesions
strangulated inguinal hernia
small bowel atresia
Crohns disease
irritable bowel syndrome
F
G
H
I
intussusception
intra-abdominal abscess
Meckels diverticulum
midgut volvulus
For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.
1
A 54-year-old woman presents to A&E with a 48-hour history of colicky abdominal pain, vomiting and abdominal distension. Basic observations on arrival are:
pulse 120/min, BP 100/75 mmHg, temperature 38C. Abdominal examination
reveals generalized tenderness, with a firm, tender, 3 4 cm swelling in the right
groin. Bowel sounds are absent.
4 Abdominal masses
A
B
C
D
E
F
G
H
I
J
K
L
diverticulosis
hepatocellular carcinoma
caecal carcinoma
psoas abscess
abdominal aortic aneurysm
ovarian cyst
For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.
1
A 75-year-old man with a 3-month history of dyspepsia presents with weight loss
and abdominal distension. On examination, a 3.5-cm, hard, irregular tender epigastric mass can be felt which moves on respiration. Percussion of the distended
abdomen reveals shifting dullness. The left supraclavicular node is palpable.
A 70-year-old woman presents with a mass in the right iliac fossa and severe
microcytic anaemia. On examination the mass is firm, irregular and 4 cm in
diameter. The lower edge is palpable.
A 35-year-old woman is worried about an abdominal mass that has grown over
the last 6 months and a similar length history of very heavy menstrual bleeding
with no intermenstrual bleeding. On examination, a knobbly mass can be felt in
the middle lower quadrant that is dull to percussion. The lower edge is not
palpable. She is otherwise well.
5 Anorectal conditions
A
B
C
D
E
F
fissure-in-ano
perianal warts
proctalgia fugax
second-degree haemorrhoids
fistula-in-ano
pilinoidal abscess
G
H
I
J
K
L
anal carcinoma
rectal prolapse
pruritus ani
ischiorectal abscess
third-degree haemorrhoids
syphilitic gumma
For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.
1
A 32-year-old woman who has recently given birth complains of excrutiating pain
on defecation that persists for hours afterwards. Rectal examination is not possible
due to pain.
A 27-year-old pregnant woman presents with constipation and bright red blood
coating her stools. On examination, two bluish tender spongy masses are found
protruding from the anus. These do not reduce spontaneously and require digital
reduction.
A 19-year-old woman presents with multiple papilliferous lesions around the anus.
right hemicolectomy
extended left hemicolectomy
Hartmanns procedure
anterior resection
subtotal colectomy
F
G
H
I
sigmoidectomy
extended right hemicolectomy
abdominoperineal resection
total colectomy
Choose the most likely operation that is required from the options above. Each
answer may be used only once.
1
A 65-year-old man is found to have a rectal carcinoma that is invading the anal
sphincter.
A 49-year-old man with a history of weight loss and anaemia of unknown origin
is found to have a large caecal tumour on colonoscopy.
intravenous mesalazine
steroid enemas
stricturoplasty
high-dose intravenous steroids
proctocolectomy with ileal pouch
F
G
H
I
J
Choose the most suitable management from the options above. Each answer may
be used only once.
1
A 28-year-old patient with Crohns disease presents with complete small bowel
obstruction. Small bowel follow-through shows short small bowel strictures.
barium swallow
flexible sigmoidoscopy
watch and wait
faecal occult blood
CT abdomen
F
G
H
I
ERCP
oesophagogastroduodenoscopy
small bowel follow-through
colonoscopy
For each clinical scenario below give the most appropriate investigation. Each
option may be used only once.
1
A 65-year-old man presents with a history of weight loss and diarrhoea. He has
noticed blood mixed in with stools.
9 Paediatric surgery
A
B
C
D
E
hydrocoele
coeliac disease
intussusception
gastroschisis
duodenal atresia
F
G
H
I
J
Wilms tumour
Hirschsprungs disease
pyloric stenosis
necrotizing enterocolitis
infantile colic
For each clinical scenario below give the most likely cause for the clinical findings and appropriate management. Each option may be used only once.
1
A 7-month-old child is brought to A&E crying inconsolably and drawing his legs
up. He has had one episode of vomiting and has been passing bloody stools. On
examination a small mass is palpable in the right upper quadrant.
A 6-week-old child is brought to A&E by his mother as she has been concerned
about severe forceful vomiting shortly after feeding. He is reported to be constantly hungry. There is no history of diarrhoea. On examination the child looks
dehydrated and malnourished. Gastric peristalsis is visible.
A newborn has failed to pass meconium in the first 48 hours and is reluctant to
feed. On examination the abdomen is distended. Plain abdominal radiography
shows distended loops of bowel with absence of air in the rectum.
10 Splenomegaly
A
B
C
D
E
F
malaria
pernicious anaemia
sarcoidosis
idiopathic thrombocytopenic
purpura
Gauchers disease
infective endocarditis
G
H
I
J
K
L
M
spherocytosis
infectious mononucleosis
cutaneous leishmaniasis
BuddChiari syndrome
myeloma
Feltys syndrome
acute lymphoblastic leukaemia
For each clinical scenario below give the most likely cause for the clinical
findings. Each option may be used only once.
1
A 75-year-old woman has noticed a fullness in the left upper quadrant. On examination, the GP feels that there is a smooth moderately enlarged spleen. There is a
past medical history of rheumatoid arthritis and high blood pressure. Routine
blood tests show a normocytic anaemia and low white cell count.
A 23-year-old man presents with a weeks history of fever and sore throat. He
developed a macular rash after being prescribed ampicillin by his GP. On examination he has enlarged posterior cervical nodes, palatal petechiae and splenomegaly.
A 16-year-old child is being investigated for gallstones. Routine blood tests show
mild anaemia and clinically there is smooth painless splenomegaly. The haematologist
recommends a direct Coombs test which is negative. Blood film shows the presence
of reticulocytes and spherocytes.
11 Ulcers
A
B
C
D
E
F
G
H
I
J
K
ischaemic ulcer
neuropathic ulcer
gumma
tuberculous ulcer
verruca
Select from the options above the type of ulcer that is being described in the
questions below. Each option may be used only once.
1
A 62-year-old man presents with a flat sloping edged ulcer over the left medial
malleolus.
A tanned 66-year-old man presents with an ulcerated lesion on the nose, with a
rolled edge.
A 60-year-old man complains of a bleeding ulcer on the upper region of the left
cheek. It has an everted edge and there are some palpable cervical lymph nodes.
Crohns disease
diverticulosis
chronic pancreatitis
acute pancreatitis
gluten-sensitive enteropathy
acute appendicitis
G
H
I
J
K
L
sigmoid volvulus
intussusception
ulcerative colitis
pyloric stenosis
small bowel obstruction
perforated duodenal ulcer
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 26-year-old student presents with bloody diarrhoea, abdominal pain and weight
loss. Barium enema reveals cobblestoning and colonic strictures.
A 45-year-old man presents with severe epigastric pain and vomiting. Abdominal
film shows absent psoas shadow and sentinel loop of proximal jejunum.
13 Complications of gallstones
A
B
C
D
E
biliary colic
gallbladder carcinoma
acute pancreatitis
gallstone ileus
ascending cholangitis
F
G
H
I
acute cholecystitis
empyema
chronic cholecystitis
mucocoele
Choose the most likely complication from the choices above. Each answer may be
used only once.
1
A 45-year-old woman presents with fever and significant right upper quadrant
pain. On examination there is marked jaundice and the nurse has reported that the
patient is having rigors. Blood tests show plasma bilirubin 250 mmol/L, ALT
200 U/L, ALP 800 U/L, WCC 23 109.
A 55-year-old man presents with constant right upper quadrant pain associated
with vomiting. He is afebrile.
A 52-year-old man presents with vomiting and severe epigastric pain radiating to
the back. Abdominal x-ray shows a dilated proximal small bowel loop.
14 Breast conditions
A
B
C
D
E
F
G
Pagets disease
phylloides tumour
mammary haemangioma
galactocoele
chronic breast abscess
carcinoma of breast
benign eczema of nipple
H
I
J
K
L
M
fibroadenoma
postpartum fat necrosis
gynaecomastia
mastitis
dermatitis herpetiformis
duct ectasia
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 75-year-old woman presents to her GP with a breast lump in the upper outer
quadrant. On examination the lump is hard and irregular. There is axillary
lymphadenopathy.
For each clinical scenario below give the most appropriate treatment. Each option
may be used only once.
1
A 92-year-old woman presents with oestrogen receptor positive stage III invasive
ductal carcinoma.
A 32-year-old patient presents with a 2.5-cm invasive ductal carcinoma. She has a
palpable axillary lymph node which reveals cancer cells on cytology. The tumour is
oestrogen receptor negative.
16 Skin lesions
A
B
C
D
E
Marjolins ulcer
Kaposis sarcoma
malignant melanoma
keratoacanthoma
keloid
F
G
H
I
J
Choose the most likely skin lesion that is described in the scenarios from the
options above. Each option may be used only once.
1
A 77-year-old patient presents with a 1.5-cm raised lesion above the right eyebrow.
On examination the lesion is pearly in appearance with rolled edges and telangiectasia on its surface.
A 60-year-old man presents with a 2.5-cm rapidly growing lesion situated on the
right side of the nose. On examination it has an everted edge with prominent
keratinization.
A 45-year-old woman presents with a dark, 8-mm lesion on the lateral aspect of
the right lower leg. It occasionally bleeds on contact.
histiocytoma
myosarcoma
ganglion
abscess
lipoma
carbuncle
furuncle
H
I
J
K
L
M
neurofibroma
sebaceous cyst
keloid
Marjolins ulcer
keratoacanthoma
osteoma
For each description of a lump(s) below give the most likely cause for the clinical
findings. Each option may be used only once.
1
A 33-year-old man presents with a swelling on the upper arm which has been
growing slowly for a number of years. Examination reveals a soft, compressible,
non-tender lobulated mass.
A 28-year-old man presents with a painless swelling on the dorsum of the right
hand. Examination reveals a smooth, spherical, tense, 1.5-cm swelling. The
overlying skin can be drawn over it.
A 65-year-old woman presents with a rapidly growing lump just below the eye.
Examination reveals a 2-cm, smooth, round, skin-coloured lump with a black
central core. The lump is freely mobile over subcutaneous tissues.
18 Pathology terminology
A
B
C
D
E
agenesis
dysplasia
hyperplasia
hypertrophy
atrophy
F
G
H
I
hypoplasia
aplasia
metaplasia
neoplasia
Choose the pathological term being described by the definitions below. Each
option may be used only once.
1
The transformation of one fully differentiated cell type into another fully differentiated cell type.
follicular carcinoma
Hashimotos disease
anaplastic carcinoma
papillary carcinoma
lymphoma
F
G
H
I
J
Riedels thyroiditis
Graves disease
follicular adenoma
medullary carcinoma
de Quervains thyroiditis
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 75-year-old woman presents with acute airway obstruction and a thyroid mass
after several weeks of worsening shortness of breath. Postmortem reveals a thyroid
mass that has invaded the trachea and surrounding structures. Histology shows
giant cells containing pleomorphic hyperchromatic nuclei.
A 38-year-old patient presents with a 2.5-cm right-sided thyroid mass. On examination there is mild enlargement of the cervical lymph nodes. A thyroidectomy is
performed and histology reveals a non-encapsulated infiltrative mass. Psammoma
bodies and epithelial cells with large clear areas within the nuclei are noted.
A 24-year-old woman presents with a diffusely enlarged thyroid gland. On examination she has a fine tremor and exophthalmos.
follicular carcinoma
Hashimotos disease
anaplastic carcinoma
endemic goitre
lymphoma
Riedels thyroiditis
G
H
I
J
K
Graves disease
follicular adenoma
medullary carcinoma
De Quervains thyroiditis
papillary carcinoma
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 45-year-old woman presents with a painless, firm, left-sided neck swelling. Fineneedle aspiration reveals the presence of multiple compact follicles. Histology
shows evidence of capsular and blood vessel invasion.
A 55-year-old African man is referred to the ENT clinic with a large, smooth goitre
that has been increasing in size for at least 20 years.
elemental diet
normal oral intake
total parenteral nutrition (TPN)
nasojejunal feeding
percutaneous endoscopic
gastrostomy (PEG)
F
G
H
I
J
Choose the most suitable means of providing nutrition from the options above.
Each option may be used only once.
1
A 29-year-old man is admitted to the surgical ward following an acute exacerbation of Crohns disease. He had a limited small bowel resection several months ago
and has subsequently developed a high enterocutaneous fistula. On examination
he appears malnourished.
A 57-year-old man with oesophageal cancer is severely malnourished due to significant dysphagia to solid food. He is able to tolerate small volumes of liquid feed
with discomfort.
A 25-year-old homeless patient who has not eaten for 24 hours requires, later in
the day, an incision and drainage procedure for a groin abscess.
hypovolaemia
sepsis
cardiac tamponade
tension pneumothorax
neurogenic shock
F
G
H
I
J
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
23 Chest trauma
A
B
C
D
E
F
G
H
I
J
K
L
haemothorax
diaphragmatic rupture
diaphragmatic contusions
myocardial contusion
pleural effusion
tension pneumothorax
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 45-year-old male is brought to A&E after suffering multiple stab wounds to the
chest. On examination the patient is in respiratory distress with poor expansion on
the right side of the chest. There is deviation of the trachea to the left. Neck veins
appear distended. SaO2 is 90 per cent on air, pulse 120/min, BP 90/55 mmHg.
A 45-year-old man is stabbed in the right side of the chest. Chest x-ray shows a
whiteout of the right lung field.
0
3
4
7
9
F
G
H
I
J
10
11
12
13
14
Calculate the Glasgow Coma Score (GCS) of the patients in the scenarios below.
1
An 8-year-old girl presents with fever, neck stiffness and photophobia. She is confused, with spontaneous eye-opening and can obey motor commands.
hyperkalaemia
iron overload
transfusion-related acute lung injury
hypothermia
non-haemolytic febrile reaction
haemolytic transfusion reaction
thrombophlebitis
H air embolus
I delayed haemolytic transfusion
reaction
K hypocalcaemia
L viral infection
M circulatory overload
Choose the most likely complication from the options above. Each option may be
used only once.
1
A 50-year-old patient presents with jaundice 5 days after receiving a red cell
transfusion.
A 24-year-old patient is noted to be flushed a few minutes after starting a red cell
transfusion. Temperature 37.8C. The temperature and symptoms respond to
paracetamol.
26 Head injury
A
B
C
D
E
scalp haematoma
concussion syndrome
diffuse axonal injury
basal skull fracture
subarachnoid haemorrhage
F
G
H
I
subdural haematoma
post-concussive syndrome
cerebral contusion
extradural haemorrhage
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 75-year-old woman is brought to A&E by her husband who reports that her
consciousness level has been fluctuating. He reports that she banged her head following a fall a few days ago but did not lose consciousness at the time. CT shows a
hyperdense crescentic lesion against the inner aspect of the left frontal skull.
There is moderate midline shift.
ANSWERS
1 Abdominal pain (i)
Answers: 1B, 2K, 3F, 4E, 5C
A 45-year-old man with a history of gallstones presents in A&E with severe
epigastric pain radiating to the back and vomiting.
B
Severe epigastric pain radiating to the back is the classical description of acute
pancreatitis. Gallstones and alcohol are the two most common causes of acute
pancreatitis. Serum amylase is usually significantly raised but this is not specific as
amylase can be raised with other conditions that present with an acute abdomen
such as cholecystitis and perforated viscus.
A 28-year-old man presents with sharp left loin and left upper quadrant pain
radiating to the groin. He is not jaundiced.
Renal colic is severe and often associated with nausea and vomiting. The classical
description is of loin pain radiating to the groin. It is very important to provide
adequate analgesia and morphine may be required. Urine dipstick is a very useful
simple investigation, and if there is no blood detected on dipstick a renal stone is
unlikely to be the causative pathology.
A 44-year-old woman presents with continuous right upper quadrant pain,
vomiting and fever. There is marked right upper quadrant tenderness when
palpating on inspiration.
Murphys sign is an indicator of acute cholecystitis. The hand is placed over the
right upper quadrant and the patient is asked to breathe in. The pain resulting
from the inflamed gallbladder moving downwards and striking the hand is severe
and arrests the inspiratory effort.
A 26-year-old male with a previous history of abdominal surgery presents with
colicky central abdominal pain rapidly followed by production of copious bilestained vomitus.
EMQ answers 29
A 72-year-old man with a history of constipation presents with increased temperature, diarrhoea and left iliac fossa pain. On examination there is tenderness
in the left iliac fossa.
M Diverticular disease is more common in the western world possibly due to the low
dietary fibre intake. The sigmoid colon is most commonly affected giving rise to
symptoms of constipation and rectal bleeding. Diverticulae may become infected
causing diverticulitis due to build-up of stagnant faecal material in a diverticulum
with obstruction of the neck of the diverticulum and mucus secretion/bacterial
overgrowth. Most simple cases of diverticulitis may be managed conservatively
with/without antibiotics. Complications to watch out for include bleeding, abscess
formation, fistulization and perforation.
EMQ answers 31
4 Abdominal masses
Answers: 1K, 2C, 3I, 4E, 5F
A 65-year-old man collapses in the street. On examination he has an abdominal mass lying above the umbilicus that is expansile and pulsatile.
K
The presence of an expansile and pulsatile mass implies the presence of aneurysm.
A true aneurysm is lined by all three layers of arterial wall, whereas a false
Gastric carcinoma should always be considered in a patient of this age complaining of dyspepsia for over a month. The presence of Virchows node (left supraclavicular node) and ascites implies disseminated disease and thus carries a poor
prognosis. This finding is sometimes referred to as a positive Troisiers sign.
A 70-year-old woman presents with a mass in the right iliac fossa and severe
microcytic anaemia. On examination the mass is firm, irregular and 4 cm in
diameter. The lower edge is palpable.
Fibroids are the commonly used name for fibromyomata which are benign
tumours of the smooth muscle of the uterus. The incidence of fibroids increases
with age. They typically present with symptoms of increased menstrual blood loss
in a middle-aged woman. Other common presentations include infertility and
symptoms due to pressure on other structures, such as urinary frequency or constipation. Fibroids vary considerably in size and may grow such that they occupy a
large part of the abdomen and compress other structures. A patient may also present with an acute abdomen following thrombosis of a fibroids blood supply (red
degeneration). Management depends on several factors, including the size of the
fibroids, symptoms, patients circumstances etc. Surgical interventions include
myomectomy, uterine artery embolism and open/laparoscopic hysterectomy.
EMQ answers 33
Pancreatic pseudocysts are usually located in the lesser sac adjacent to the pancreas. They occur due to ductal leakage following inflammation of the pancreas
(acute or chronic). Chronic pancreatitis is the most common cause of pancreatic
pseudocyst. These patients may present non-specifically with abdominal discomfort, nausea, early satiety etc. Complications of pancreatic pseudocyst include
infection (most common), obstruction (of common bile duct leading to jaundice)
and perforation. Very rarely the pseudocyst can enlarge such that it erodes nearby
vessels causing pseudoaneurysm formation which can be fatal. Fortunately most
pseudocysts resolve spontaneously. CT is the investigation of choice and typically
shows a round/ovoid fluid-filled cavity encapsulated by a fibrous wall. A pseudocyst does not have a true epithelial lining. Pancreatic pseudocysts can be treated
by drainage if it is felt that there is a high risk of complication.
5 Anorectal conditions
Answers: 1E, 2A, 3F, 4K, 5B
A 28-year-old man with Crohns disease complains of watery discharge from a
puckered area 2 cm from the anal canal.
E
Fistulae are a well-recognized complication of Crohns disease. A full rectal examination is important to detect other causes of fistula-in-ano (e.g. rectal carcinoma).
Management is initially conservative with use of antibiotics and drainage if there
is abscess formation. If surgery is indicated then it is important to determine the
anatomy of the fistula by means of a fistulogram/MRI as the course/extent determines the intervention. Fistula surgery is specialist surgery and there are several
approaches/techniques that have been adopted. However, in simple terms a low
anal fistula can usually be safely laid open over a probe. Such a procedure cannot
be carried out for a high fistula because of risk of damage to the anal sphincters.
In these cases the use of a cutting seton or more advanced surgery is indicated.
A 32-year-old woman who has recently given birth complains of excrutiating
pain on defecation that persists for hours afterwards. Rectal examination is not
possible due to pain.
A Anal fissures are exquisitely tender and therefore a rectal examination is simply
not possible. The patient is often constipated as defecation is so painful. This
results in a vicious cycle as the stools become harder, resulting in defecation
becoming more difficult and painful. Management is initially medical with liberal
use of stool softeners to break the cycle of pain. GTN/diltiazem ointment may be
applied topically to relax the sphincter. Surgical procedures include lateral internal
sphincterotomy and controlled sphincter dilatation.
Pilinoidal disease results from hair follicle occlusion along the natal cleft. This may
manifest as abscess and sinus formation. This man is likely to have an abscess
which will require incision and drainage. Good postoperative wound care is vital
for a good result. Incision and drainage may be complicated with sinus formation
that may itself need further surgical intervention. The patient should be warned
about the risk of recurrence.
A 27-year-old pregnant woman presents with constipation and bright red
blood coating her stools. On examination, two bluish tender spongy masses are
found protruding from the anus. These do not reduce spontaneously and
require digital reduction.
Spongy vascular tissue surrounds and helps close the anal canal. However, if these
cushions enlarge, varices of the superior rectal veins can prolapse and bleed to
form haemorrhoids/piles.
First-degree haemorrhoids remain in the rectum.
Second-degree haemorrhoids prolapse through the rectum on defecation but
spontaneously reduce.
Third-degree haemorrhoids can only be reduced with digital reduction.
Fourth-degree haemorrhoids remain prolapsed.
Constipation resulting in prolonged straining is a common cause and so a
high-fibre diet may be a useful preventive measure. Sclerotherapy and rubber-band
ligation can be provided for symptomatic haemorrhoids in the outpatient setting.
Thrombosed, strangulated piles or large symptomatic prolapsed haemorrhoids that
are not amenable to other therapy may be treated with haemorrhoidectomy
(e.g. Milligan Morgan procedure or a stapling procedure).
A 19-year-old woman presents with multiple papilliferous lesions around
the anus.
EMQ answers 35
Hartmanns procedure involves excision of part of the left colon with end
colostomy and closure or exteriorization of the distal remnant. The main indications are:
Relief of obstruction for example in a patient presenting with obstruction
secondary to sigmoid colon carcinoma. The malignancy with appropriate margins can be excised and a colostomy formed. The Hartmanns procedure can be
reversed at a later date.
Perforation of sigmoid colon. The patient presents as an emergency with a perforated sigmoid diverticulum/secondary to undiagnosed malignancy. A primary
anastomosis is not possible with the degree of inflammation and peritonitis.
Refractory sigmoid volvulus. Occasionally sigmoid volvulus fails to resolve by
conservative measures/passing of flatus tube etc., and emergency surgery is
required. If primary anastomosis is deemed likely to fail, then a Hartmanns
procedure is performed in the first instance (can be reversed later depending on
the case).
A 49-year-old man with a history of weight loss and anaemia of unknown
origin is found to have a large caecal tumour on colonoscopy.
debate depending on the position of the tumour). These patients may need a
defunctioning loop colostomy to reduce the risk of anastomotic breakdown.
Crohns disease may affect any part of the gastrointestinal tract from mouth to
anus. In this way, curative surgery is less likely in Crohns disease than ulcerative
colitis. Principles of surgical intervention in Crohns disease are, therefore, to keep
procedures to a minimum (conserving bowel if possible). In this patient where the
strictures are short, use of stricturoplasty/balloon dilatation is a reasonable surgical option. If the strictures are long or not amenable to stricturoplasty, then a limited bowel resection can be carried out.
EMQ answers 37
9 Paediatric surgery
Answers: 1C, 2H, 3G, 4E
A 7-month-old child is brought to A&E crying inconsolably and drawing his
legs up. He has had one episode of vomiting and has been passing bloody
stools. On examination a small mass is palpable in the right upper quadrant.
C
(causing drawing up of the legs as in infantile colic), vomiting and the passage of
the well described redcurrant jelly stools. This description results from the consistency of the stool that is composed of a mixture of blood, mucus and sloughed
bowel mucosa. A sausage-shaped mass may also be palpable in the right
hypochondrium.
Rehydration, correction of electrolyte abnormalities and nasogastric decompression are important initial measures. The condition may be treated with careful
reduction using air or contrast enema. If this fails or there is obvious
peritonitis/bowel perforation, surgery is indicated.
A 6-week-old child is brought to A&E by his mother as she has been concerned
about severe forceful vomiting shortly after feeding. He is reported to be constantly hungry. There is no history of diarrhoea. On examination the child looks
dehydrated and malnourished. Gastric peristalsis is visible.
H Pyloric stenosis (infantile hypertrophic pyloric stenosis) is characterized by hypertrophy and hyperplasia of the muscular layers of the pylorus resulting in an elongated thickened pylorus and a narrow gastric antrum. The incidence is around 3 in
1000 with males affected four times more frequently than females. The condition
is most common in first-born males. Causation is multifactorial with both genetic
and environmental variables at play.
The condition usually presents within the first few weeks of life. The most common
history is that of episodes of projectile vomiting leaving the affected child constantly hungry. On examination gastric peristalsis may be observed and there may
be the classical olive-shaped mass just right of the epigastrium that is palpable
after a test feed. Exam questions often allude to the biochemical picture of
hypochloraemic hypokalaemic metabolic alkalosis that results from the excessive
vomiting.
The most important intervention is stabilization of the patient with rehydration
and correction of electrolyte abnormalities. Once this has been achieved the condition may be corrected surgically with a Ramstedts pyloromyotomy.
A newborn has failed to pass meconium in the first 48 hours and is reluctant
to feed. On examination the abdomen is distended. Plain abdominal radiography shows distended loops of bowel with absence of air in the rectum.
G Hirschsprungs disease results from the congenital absence of parasympathetic ganglion cells in the myenteric/submucous plexuses of the distal colon/rectum. The disease has an incidence of around 1 in 5000 and is around four times more common
in males. Abdominal distension and failure to pass meconium in the first 48 hours
of life are common presentations. Older children may present with chronic constipation but such delayed presentation is now rare. Definitive diagnosis is established
by rectal biopsy revealing absence of ganglion cells. Management is surgical and
involves excision/bypass of the affected aganglionic segment of bowel.
EMQ answers 39
Duodenal atresia (DA) commonly presents with bile-stained vomiting in the first
few hours of life. The condition has an incidence of about 1 in 6000 but there is a
strong association with Downs syndrome (up to 30 per cent of DA patients have
the trisomy 21 phenotype). The double bubble appearance on chest x-ray due to
dilatation of stomach and duodenum is a characteristic finding that is frequently
alluded to in exam questions.
Initial management involves fluid resuscitation and correction of electrolyte
abnormalities. A nasogastric tube should be passed to allow decompression.
Treatment is surgical and a duodenoduodenostomy is the procedure of choice.
10 Splenomegaly
Answers: 1L, 2H, 3A, 4J, 5G
A 75-year-old woman has noticed a fullness in the left upper quadrant. On
examination, the GP feels that there is a smooth moderately enlarged spleen.
There is a past medical history of rheumatoid arthritis and high blood pressure.
Routine blood tests show a normocytic anaemia and low white cell count.
L
11 Ulcers
Answers: 1F, 2A, 3C, 4G, 5H
A 62-year-old man presents with a flat sloping edged ulcer over the left medial
malleolus.
F
Venous ulcers are usually found around the lower third of the leg. It is important
to remember that in a longstanding venous ulcer there may be malignant change
to form a squamous cell carcinoma. This is known as a Marjolins ulcer. Look out for
signs of venous hypertension manifested by skin changes (e.g. lipodermatosclerosis,
haemosiderin staining).
EMQ answers 41
A tanned 66-year-old man presents with an ulcerated lesion on the nose, with
a rolled edge.
A Basal cell carcinoma (also known as a rodent ulcer) is a locally invasive carcinoma
that is more common on areas of sun-exposed skin. The carcinoma starts as a
slow-growing nodule that may be itchy or sometimes bleeds. There is necrosis of
the centre, leaving a rolled edge. Basal cell carcinoma does not metastasize and
surrounding lymph nodes should not be enlarged.
A 60-year-old man complains of a bleeding ulcer on the upper region of the left
cheek. It has an everted edge and there are some palpable cervical lymph nodes.
C
Bleeding is more common in squamous cell carcinoma than basal cell carcinoma
and, unlike with the latter, there may be enlarged lymph nodes. Squamous cell
carcinoma has a characteristic everted edge.
A 71-year-old man presents with an exquisitely painful punched-out ulcer on
the tip of the right big toe. On examination, the surrounding area is cold.
G Ischaemic ulcers can be excruciatingly painful to the extent that changing the
overlying dressing can lead to pain lasting for several hours afterwards. Ischaemic
ulcers are characteristically deeper than venous ulcers and can penetrate down to
the bone. The surrounding area is cold due to ischaemia.
A 58-year-old diabetic presents with a painless punched-out ulcer on the sole
of the right foot. The surrounding area has reduced pain sensation.
H Neuropathic ulcers occur due to impaired sensation resulting from neurological
deficit of whatever cause. Diabetes mellitus is the most common cause of neuropathic ulcers. They are characteristically painless.
Free gas under the diaphragm could result from any perforated viscus (e.g. colon)
and is not specific for gastric/duodenal perforation.
Abdominal film of an elderly constipated woman shows a dilated inverted U
loop of bowel.
G The sigmoid colon is the most common site of volvulus in the gastrointestinal
tract. The condition involves the sigmoid colon twisting around its mesenteric axis
causing obstruction. The condition tends to occur in the elderly. The condition can
be treated by sigmoidoscopy and the insertion of a flatus tube per rectum to allow
decompression.
This is toxic megacolon and a presentation of severe ulcerative colitis. It is a medical and surgical emergency and there is significant risk of perforation.
A 26-year-old student presents with bloody diarrhoea, abdominal pain and
weight loss. Barium enema reveals cobblestoning and colonic strictures.
A Strictures and fistulae are typical of Crohns disease. Ulceration and fissuring give
rise to rose thorn ulcers. There is discontinuous involvement of the gastrointestinal tract with skip lesions, whereas ulcerative colitis is associated with continuous
disease.
A 45-year-old man presents with severe epigastric pain and vomiting. Abdominal
film shows absent psoas shadow and sentinel loop of proximal jejunum.
D The absence of the psoas shadow is due to a build-up of retroperitoneal fluid. The
sentinel loop refers to a segment of gas-filled proximal jejunum. However, it is
important to remember that an abdominal plain film can be completely normal in
a patient presenting with acute pancreatitis.
13 Complications of gallstones
Answers: 1E, 2A, 3D, 4C
A 45-year-old woman presents with fever and significant right upper quadrant
pain. On examination there is marked jaundice and the nurse has reported that
the patient is having rigors. Blood tests show plasma bilirubin 250 mmol/L,
ALT 200 U/L, ALP 800 U/L, WCC 23 109.
E
A Biliary colic is a constant right upper quadrant pain (unlike renal colic) as it results
from the spasm of gallbladder muscle against a stone lodged in Hartmanns pouch
(at neck of gallbladder) or the cystic duct.
EMQ answers 43
Acute cholecystitis presents with biliary colic symptoms. The key difference is that
in acute cholecystitis there is development of inflammation due to the mechanical
obstruction that can result in superimposed bacterial infection. These patients will
therefore show signs of inflammation/infection (pyrexia, tachycardia, increased
white cell count).
A 63-year-old man presents with a 3-day history of worsening abdominal pain
and vomiting. Abdominal x-ray reveals dilated loops of small bowel and air in
the biliary tree.
D Gallstone ileus is caused by a mechanical obstruction of the intestine by a
gallstone. This results due to the formation of a fistula between the gallbladder
and the small intestine allowing the passage of the gallstone and consequent
impaction. Imaging may reveal the typical findings of small bowel obstruction and
air in the biliary tree.
A 52-year-old man presents with vomiting and severe epigastric pain radiating
to the back. Abdominal x-ray shows a dilated proximal small bowel loop.
C
14 Breast conditions
Answers: 1F, 2M, 3H, 4A, 5K
A 75-year-old woman presents to her GP with a breast lump in the upper outer
quadrant. On examination the lump is hard and irregular. There is axillary
lymphadenopathy.
F
A hard irregular lump is a cause for concern and warrants further investigation.
A 53-year-old woman presents with nipple retraction and a greeny-yellow
discharge. Ultrasound shows dilated breast ducts.
EMQ answers 45
communication with the primary breast tumour and receives lymph fluid from it.
The histological status of the sentinel node is an accurate predictor of the status
of the rest of the axillary lymph nodes in breast cancer patients. Identification of
the sentinel node involves injecting radioactive colloid at the site of the primary
tumour followed by a nuclear medicine scan under a gamma camera. At operation,
combination of a blue dye and use of a gamma detection probe lead the surgeon
to this lymph node. There is a very low morbidity associated with this procedure
and over 60 per cent of patients in the UK can be spared from the side-effects of
axillary lymph node dissection which is the procedure of choice in patients with
proven axillary disease.
A 32-year-old patient presents with a 2.5-cm invasive ductal carcinoma . She
has a palpable axillary lymph node which reveals cancer cells on cytology. The
tumour is oestrogen receptor negative.
I
This woman has proven axillary lymph node disease and therefore axillary lymph
node dissection is warranted. The tumour is oestrogen receptor negative and
therefore tamoxifen is not indicated. For a young patient with advanced disease,
adjuvant chemotherapy is indicated to reduce the risk of recurrence.
Primary drug treatment in a form of endocrine or chemotherapy can be used in
other circumstances too. In patients who have inoperable locally advanced
tumour, primary drug therapy aims to make it possible to perform the procedure.
Additionally, in patients with large primary tumours, it could shrink the tumour
down so that breast-conserving therapy can be offered to the patient.
16 Skin lesions
Answers: 1F, 2H, 3C, 4E
A 77-year-old patient presents with a 1.5-cm raised lesion above the right
eyebrow. On examination the lesion is pearly in appearance with rolled edges
and telangiectasia on its surface.
F
Basal cell carcinoma typically occurs over areas of sun-exposed skin, especially the
head and neck. It is slow-growing and rarely metastasizes. However, if left to
progress it can cause significant local ulceration. The common nodular basal cell
carcinoma is typically described as having a translucent/pearly appearance with
surface telangiectasia. It is often described as having a rolled edge. Surgical excision with an appropriate margin is the standard treatment, but curettage,
cryotherapy and laser ablation therapy are other treatments that are offered for
particularly small lesions.
EMQ answers 47
The incidence of melanoma is rising and exposure to sunlight is the major aetiological factor. The majority of melanomas arise from pre-existing moles and any
changes in size, shape or colour, bleeding or itching should prompt the doctor to
perform a biopsy. Excision biopsy is the accepted method. There are different types
of melanomas, including superficial spreading, nodular, lentigo maligna, acral
lentiginous and amelanotic melanoma. The superficial spreading melanoma is the
commonest type comprising 70 per cent of melanomas.
Tumour thickness described by Breslow (Breslow thickness) and expressed in
millimetres is the most reliable independent prognostic indicator. Presence or
absence of disease within the sentinel lymph node (see answer to Q3 in 15) is
regarded as another very important prognostic indicator. Presence or absence of
ulceration is another important prognostic indicator, as is melanoma site. For
example, melanomas in head and neck and acral regions have poorer prognosis.
Surgery in the form of wide local excision is the standard management. The thickness of the primary melanoma determines the extent of surgery and the excision
margins. In melanomas less than 1 mm, a 1-cm excision margin is acceptable.
Between 1 and 2 mm a 2-cm excision margin is appropriate; for melanomas over
2 mm, a 3-cm excision margin is the common practice.
Intermediate thickness melanoma patients (Breslow thickness 14 mm) are offered
sentinel node biopsy for nodal staging.
Keloid refers to the formation of excessive scar tissue following trauma to the
skin. This is believed to be due to an abnormality in the normal wound healing
process involving excessive collagen accumulation. It is important to note that
keloid may spread away from the initial site of trauma.
Keloid is more common in black patients, and the risk of developing scarring
diminishes with age.
Treatment options for keloid are generally unsatisfactory. Examples include corticosteroid injections, excision surgery and cryotherapy. Prevention is the key management strategy. Minimizing incision size and appropriate closure of wounds with
minimal tension along relaxed skin tension lines is crucial if surgery is carried out
on high-risk individuals.
Sebaceous cysts are benign cystic lesions that most commonly occur on the scalp,
face, neck, chest and back. There are no sebaceous glands on the palms of the
hand and the soles of the feet. The punctum visible on the surface of the lump is
virtually diagnostic of sebaceous cyst. The skin cannot be drawn over a sebaceous
cyst. If punctured, the cyst may discharge keratinized material that is often
described as toothpaste-like in consistency. Sebaceous cysts may be excised under
local anaesthetic.
A 33-year-old man presents with a swelling on the upper arm which has been
growing slowly for a number of years. Examination reveals a soft, compressible,
non-tender lobulated mass.
This is a typical history of a benign lipoma with slow growth over a number of
years. They are generally non-tender and lobulation is the key diagnostic feature.
A 28-year-old man presents with a painless swelling on the dorsum of the
right hand. Examination reveals a smooth, spherical, tense, 1.5-cm swelling.
The overlying skin can be drawn over it.
EMQ answers 49
18 Pathology terminology
Answers: 1H, 2C, 3I, 4D
The transformation of one fully differentiated cell type into another fully differentiated cell type.
H Metaplasia is defined as the transformation of one fully differentiated cell type
into another fully differentiated cell type. It can be broadly classified into epithelial metaplasia and connective metaplasia. Squamous metaplasia is the most common form of epithelial metaplasia (e.g. ciliated respiratory epithelium in response
to smoking). Glandular metaplasia is a less common form of epithelial metaplasia
but is best exemplified by the condition known as Barretts oesophagus. This refers
to the metaplastic change from squamous oesophageal epithelium to columnar
glandular epithelium due to acid reflux.
An increase in the number of cells within tissue.
C
Neoplasia is characterized by abnormal excessive uncoordinated growth that persists despite the removal of any predisposing stimulus. Dysplasia is non-neoplastic
proliferation that has the capacity to progress to neoplasia. Clinically significant
sites of dysplasia include the bronchus, cervix and oesophagus. Environmental factors (e.g. smoking and alcohol ingestion) may predispose to dysplasia in some sites.
An increase in the size of cells within tissue.
D Hypertrophy is an increase in the size of tissue due to an increase in the size of the
cells. It may be physiological or pathological. Examples of physiological hypertrophy include the enlargement of the uterus in pregnancy and the hypertrophy of
skeletal muscle with exercise. Examples of pathological hypertrophy are the development of cardiomyopathy and some congenital muscular dystrophies.
D Papillary carcinoma accounts for 6070 per cent of all malignant thyroid neoplasms. It is a well-differentiated and minimally invasive tumour that carries a
good prognosis even with lymphatic spread (which is common). The classical histological findings are Orphan Annie nuclei and psammoma bodies. Orphan Annie
nuclei (named after a New York cartoon strip character) have characteristic clear
areas within the nucleus giving them the appearance of orphan eyes. Psammoma
bodies are spiral rings of calcification that are a highly specific finding to papillary
carcinoma.
EMQ answers 51
Medullary carcinoma of the thyroid originates in the parafollicular calcitonin producing C-cells of the thyroid gland. It usually presents as an isolated neck lump,
This patient has an enterocutaneous fistula and markedly inflamed bowel secondary to Crohns disease. Nutrition provided enterally is not indicated as there will be
insufficient absorption and enteral feeds will aggravate the inflammation. A
high/proximal enterocutaneous fistula is a clear indication for TPN.
EMQ answers 53
A 40-year-old woman is involved in a road traffic accident and suffers significant head injuries with associated maxillofacial trauma. A prolonged recovery
is expected.
E
This patient is severely malnourished and will benefit from preoperative enteral
feeding. The obstruction is in the oesophagus; so if one can bypass the obstruction
with a nasogastric tube and feeding is tolerated, this is the optimal route.
Although he is tolerating oral fluids, he is finding this uncomfortable and large
volumes of liquid nutritional supplementation is neither viable not effective in a
severely malnourished patient.
A 25-year-old homeless patient who has not eaten for 24 hours requires, later
in the day, an incision and drainage procedure for a groin abscess.
H This patient will be undergoing minor surgery and there is no indication for preoperative feeding. She may be kept nil by mouth and given intravenous fluids to
keep her well hydrated. In general, some form of nutritional support should be
considered in patients if there is an inability to sustain an adequate dietary intake
for more than 3 days.
also associated with an increased JVP due to central venous compression. Cardiac
tamponade is also possible but one might expect abnormality in the heart sounds
(e.g. muffling) or a rise in the JVP. The most likely cause for the circulatory compromise in this patient is hypovolaemia secondary to blood loss from the femoral
fracture.
Femoral and pelvic fractures can be associated with significant blood loss (can be
around 11.5 L). In this situation rapid intravenous fluid boluses are the immediate
measure required to stabilize the patients circulation and thus maintain tissue
perfusion.
A 35-year-old patient complains of shortness of breath and palpitations
shortly after admission to the surgical ward from A&E for management of
acute cholecystitis. Observation shows sudden drop in blood pressure to
90/40 mmHg with accompanying tachycardia. On examination there is marked
erythema around the intravenous cannula on the dorsum of the left hand.
H This patient has suddenly become tachycardic and hypotensive and is short of
breath. The key point in the examination is the presence of erythema around the
cannula. The patient has only just been admitted for acute cholecystitis and it is
unlikely to be infected. The patient could have suffered a pulmonary embolus but is
not suffering from any chest pain and there is nothing in the history to suggest any
predisposing risk. The acute cholecystitis could result in systemic sepsis, but one
might expect other markers to be mentioned (e.g. temperature). It is more likely
that the patient is suffering from an anaphylactic reaction to the intravenous
antibiotics given after arriving on the ward. Management includes high-flow oxygen, steroids, adrenaline (epinephrine) and fluid resuscitation.
A 68-year-old patient is brought back to the ward following uncomplicated
abdominal artery aneurysm repair. He had been suffering from significant pain
postoperatively and was seen by the acute pain team about 15 minutes ago.
The nurse calls you to review as the blood pressure has dropped to
90/50 mmHg. Pulse is 60/min. He feels a little dizzy but is not in pain. Urine
output has been adequate postoperatively and CVP is +12.
E
This patient has dropped his blood pressure but is maintaining a pulse on the
lower side of normal. He has a CVP of +12 and, although central venous pressures
should be interpreted as a trend (e.g. by looking at responses to a fluid challenge),
he is unlikely to be hypovolaemic. With acute blood loss one would also expect the
patient to mount a tachycardia before dropping blood pressure. Urine output is
also good. The key information is that the patient has just been seen by the acute
pain team. After such major surgery it is likely that the patient has had an epidural
for analgesia. Given that there is a drop in blood pressure in a well-filled patient
with a normal pulse/bradycardia, it is possible that an epidural bolus has been
delivered for pain relief which caused a transient sympathetic block. This vasodilates the circulation giving a rapid drop in venous pressure and, therefore, preload
and cardiac output.
EMQ answers 55
23 Chest trauma
Answers: 1L, 2D, 3G, 4F
A 45-year-old male is brought to A&E after suffering multiple stab wounds to
the chest. On examination the patient is in respiratory distress with poor
expansion on the right side of the chest. There is deviation of the trachea to
the left. Neck veins appear distended. SaO2 is 90 per cent on air, pulse
120/min, BP 90/55 mmHg.
L
D The hallmark of flail chest is paradoxical chest movements (i.e. indrawing of the
chest wall with inspiration and outward movement with expiration). This occurs
when a section of the rib cage becomes independent of the rest of the chest wall
(at least two ribs are fractured in at least two places). The condition is associated
with significant ventilatory compromise due to severe pain as well as the obvious
disruption to the mechanics of the chest wall.
Treatment involves oxygen therapy, adequate analgesia (may need thoracic epidural)
and careful monitoring. The patient may need assistance with ventilation due to
hypoxia (from pulmonary contusions) or inadequate spontaneous ventilation.
A 45-year-old man is stabbed in the right side of the chest. Chest x-ray shows
a whiteout of the right lung field.
G The chest x-ray findings are consistent with significant haemothorax. With a large
haemothorax there will be dullness to percussion and reduced air entry on the
affected side. Primary management involves insertion of a large-bore chest drain.
A 26-year-old man is brought to A&E in extremis after suffering a single stab
wound to the left side of the chest. On examination the patient is tachypnoeic,
heart sounds are muffled and blood pressure is 90/55 mmHg despite intravenous fluid resuscitation.
F
Penetrating trauma to the pericardium results in the filling of the pericardial space
with blood which limits the expansion of the heart. Acute cardiac tamponade is
classically associated with Becks triad of muffled heart sounds, hypotension and
raised JVP. A paradoxical rise in the JVP on inspiration is difficult to detect clinically, but distended neck veins are more easy to spot. The emergency treatment of
choice is pericardiocentesis.
Eye-opening (E)
4
3
2
1
EMQ answers 57
Motor (M)
6 Normal obeys simple commands.
5 Localizing a localizing response is a purposeful movement towards a changing painful stimulus. Pain stimuli include application of nail-bed pressure,
supraorbital pressure and sternal rubbing.
4 Withdrawing withdrawal of limb in response to pain.
3 Flexor pain stimulus causes abnormal flexure of limbs (decorticate posture).
The classical decorticate posture involves flexed arms, clenched fists and
extended legs. The arms are pointed towards the body with the wrists and
fingers bent and held on the chest.
2 Extensor pain stimulus causes limb extension (decerebrate posture). The classical decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head.
1 No response to pain.
An 86-year-old man is brought to A&E with a suspected subarachnoid haemorrhage. On examination he is moaning incomprehensibly with his eyes closed.
Nail-bed pressure causes limb flexion and eye-opening.
D This patient has closed eyes which open with a painful stimulus (E2), moans
incomprehensibly (V2) and flexes limbs with pain (M3). Total GCS is 7.
An 8-year-old girl presents with fever, neck stiffness and photophobia. She is
confused, with spontaneous eye-opening and can obey motor commands.
J
Confusion is a sensitive marker of altered conscious state and this patient will
score 4 out of 5 for verbal response. Overall GCS is 14.
A homeless man is brought to A&E by paramedics after being discovered by a
commuter in an unconscious state. There are no motor responses to pain and
eye-opening and verbal responses cannot be elicited.
This patient is likely to have a very poor prognosis with a GCS score of 3 (E1, V1,
M1). Note that 3 is the lowest GCS score possible when all modalities can be
assessed.
A 78-year-old woman is found unresponsive to pain or speech on the ward by
a nurse 3 days after carotid endarterectomy. On examination there is no
speech, no eye-opening to pain, and there is abnormal rigid extension of her
arms and legs.
This patient may have suffered an embolic cerebrovascular accident as a complication of carotid artery surgery. The GCS is E1, V1, M2 (patient extending to pain), so
the total is 4.
This is a presentation of acute haemolytic transfusion reaction due to ABO incompatibility. This is a medical emergency as there is massive intravascular haemolysis
of the transfused cells and activation of the coagulation cascade and disseminated
intravascular coagulation may occur.
As soon as an incompatibility reaction is suspected the transfusion should be stopped
and resuscitation of the patient instituted. Repeat grouping should be carried out
on the donor and patient to confirm the diagnosis. A direct antiglobulin test
(Coombs test) should be carried out on the recipient post-transfusion sample.
A 50-year-old patient presents with jaundice 5 days after receiving a red cell
transfusion.
Non-haemolytic febrile transfusion reactions are now less common due to the use
of leucocyte-depleted blood. Febrile reactions are usually attributed to reactions
between recipient antibodies reacting with white cell antigens/fragments in the
donor blood or pyretic cytokines (e.g. IL-1) which accumulate in the blood product
during storage. They are more common in patients who have had previous transfusions. As fever can be the presenting sign of more serious haemolytic reaction, it is
EMQ answers 59
26 Head injury
Answers: 1H, 2F, 3D, 4C
A 24-year-old student is brought to A&E after being assaulted outside a club.
On examination, GCS 14 (confused) and he is under the influence of alcohol.
CT reveals small areas of haemorrhage throughout the frontal region. He is
admitted to the surgical ward for neuro-observations; 24 hours later the
nurses report that he is increasingly confused and restless with GCS 12
(confused, localizing and eye-opening to speech).
H A cerebral contusion is essentially a bruise of the brain tissue. Contusions most commonly occur along the undersurface and poles of the frontal and temporal lobes.
These brain areas are more susceptible to trauma against the ridges of the skull.
Significant cerebral oedema may develop around these contusions that can increase
intracranial pressure. For this reason, patients need to be closely monitored and may
need repeat imaging. Significant contusions may require operative intervention.
A 75-year-old woman is brought to A&E by her husband who reports that her
consciousness level has been fluctuating. He reports that she banged her head
following a fall a few days ago but did not lose consciousness at the time.
CT shows a hyperdense crescentic lesion against the inner aspect of the left
frontal skull. There is moderate midline shift.
F
Following head injury, there may be tearing of the bridging veins between the
cerebral cortex and venous sinuses giving rise to bleeding in the subdural space.
A significant haematoma can give rise to increasing intracranial pressure, midline
shift and ultimately tentorial hernation.
It is important to remember that even minor head injury can precipitate a subdural haemorrhage, especially in the elderly and alcoholics where there is more
brain atrophy. Acute haemorrhage gives rise to a hyperdense (white) crescentic
lesion concave against the skull. Operative intervention involves craniotomy and
evacuation of haematoma.
A 42-year-old man is found unconscious on the street. On examination there is
bruising around both eyes and a clear nasal discharge.
D This man is showing signs of a basal skull fracture. The presenting symptoms and
signs depend on the region of skull fracture. Anterior cranial fossa fractures may
present with symptoms of anosmia (loss of smell) and signs of rhinorrhoea
(cerebrospinal fluid leak through cribriform plate injury) and periorbital ecchymosis (the classical racoon eyes). Symptoms of middle cranial fossa fracture include
hearing loss and vertigo.
Signs include Battles sign (bruising behind the ear signifying temporal bone fracture), haemotympanum and cranial nerve palsies (V, VI, VII, VIII are at risk).
Posterior cranial fossa involvement may be associated with cranial nerve palsies
(IX, X, XI at risk) and brainstem compression signs.
A 25-year-old was involved in a high-speed road traffic accident 48 hours
ago. He has been comatosed since the injury. There are no major abnormalities
on CT.
C
Diffuse axonal injury (DAI) arises from the significant shearing forces associated
with accelerationdeceleration and twisting brain injury. The initial pathology is
associated with the mechanical tearing of the axons, but there is also secondary
brain injury later due to the initiation of biochemical cascades (associated with
calcium influx).
DAI carries a poor prognosis and is associated with a persistent vegetative state.
CT may show evidence of multiple cerebral contusions or may be normal. MRI is
more sensitive at detecting DAI.
SECTION 2: EMQS IN
ORTHOPAEDIC SURGERY
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
Hand conditions
Arthritis
Joint pain
Pain in the hip
Back pain
Complications of fractures
Management of fractures
Fall on the outstretched hand
Shoulder conditions
Knee conditions
Management of painful joints
Foot conditions
Lower limb nerve lesion
Upper limb nerve injury (i)
Upper limb nerve injury (ii)
QUESTIONS
27 Hand conditions
A
B
C
D
E
F
Dupuytrens contracture
trigger finger
carpal tunnel syndrome
ulnar collateral ligament injury
ulnar nerve injury
De Quervains stenosing
tenovaginitis
G
H
I
J
K
L
ganglion
scaphoid fracture
osteosarcoma
osteoarthritis of first MCP
radial nerve injury
fibrous dysplasia
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 74-year-old man presents with inability to extend the ring finger. On examination his ring finger is locked in flexion but can be released with manipulation.
A 42-year-old woman presents with a firm swelling over the dorsum of the wrist.
It has been fluctuating in size and causes discomfort when typing.
A 36-year-old woman presents with pain over the radial aspect of the wrist. On
examination pain is elicited by forced adduction and flexion of the thumb.
A 24-year-old presents with pain and swelling over the base of thumb following a
skiing accident. His grip is weak.
28 Arthritis
A
B
C
D
E
F
G
psoriatic arthritis
discoid lupus erythematosus
rheumatoid arthritis
polymyalgia rheumatica
systemic lupus erythematosus
cervical spondylosis
lumbar spondylosis
H
I
J
K
L
M
N
Reiters syndrome
Sjgrens syndrome
ankylosing spondylosis
septic arthritis
gout
osteoporosis
osteoarthritis
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 54-year-old woman presents to her GP with pain and swelling affecting her
fingers, wrists, knees and feet. On examination there are signs of ulnar deviation
and subluxation at the MCP joints. There are mild effusions over the painful joints
and they are warm on palpation. She suggests that the symptoms are worse in the
morning.
A 30-year-old woman complains of joint pain in her hands and feet. Chest x-ray
shows reduced lung volumes.
A 22-year-old man presents with an acute arthritis of the left knee, dysuria and
bilateral conjunctivitis. He has recently suffered from gastroenteritis.
A 45-year-old woman presents with bilateral painful deformed distal interphalangeal joints. Examination reveals discoloration and onycholysis of the nails.
29 Joint pain
A
B
C
D
E
F
G
psoriatic arthritis
polymyositis
rheumatoid arthritis
polymyalgia rheumatica
systemic lupus erythematosus
haemarthrosis
lumbar spondylosis
H
I
J
K
L
M
Reiters syndrome
osteosarcoma
pseudogout
septic arthritis
gout
osteoporosis
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 64-year-old patient who has recently been started on medication for hypertension presents with a very painful, hot, swollen metatarsophalangeal joint.
A 12-year-old haemophiliac presents to A&E with severe pain after falling over
and banging his right knee.
A 55-year-old man presents to A&E with fever and an exquisitely painful right
knee. On examination his right knee is red, hot and swollen. Purulent fluid is aspirated from the joint.
A 60-year-old woman presents with a painful swollen knee. X-ray shows chondrocalcinosis and joint aspiration reveals the presence of weakly positive birefringent
crystals.
A 65-year-old woman presents with a 1-month history of pain and stiffness in her
shoulders, worse in the mornings. She says she was treated in hospital last year for
headache and jaw pain.
H
I
J
K
L
M
septic arthritis
fractured sacroiliac joint
fractured neck of femur
Charcot joint
idiopathic growth retardation
Perthes disease
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
An obese 12-year-old boy presents with pain in his right hip. On examination the
hip is flexed, abducted and externally rotated. His mother has suffered from
tuberculosis in the past.
A 6-year-old boy presents with a pain in the hip and a limp. All movements at the
hip are limited. X-ray shows decrease in size of the femoral head with patchy
density.
A 2-year-old girl presents to the orthopaedic clinic with a waddling gait. Her
mother says that there has been a delay in walking. On examination there is an
extra crease on the left thigh.
An 8-year-old boy presents to A&E with a marked limp and pain in the right hip
which resolves within 48 hours. X-rays show no abnormality at the hip or other
joint involvement. Bone scan 2 weeks later is also normal.
31 Back pain
A
B
C
D
E
F
Pagets disease
polymyositis
Scheuermanns disease
vertebral disc prolapse
osteomyelitis
Reiters disease
G
H
I
J
K
myeloma
rheumatoid arthritis
Potts disease
spinal stenosis
ankylosing spondylitis
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 22-year-old man complains of stiffness in the lower back and buttock pain that
is relieved by exercise. He also suffers from bouts of painful red eye. ESR is raised.
X-ray shows blurring of the upper vertebral rims of the lumbar spine.
A 60-year-old woman presents with constant backache. ESR and serum calcium
are markedly elevated.
A 13-year-old girl complains of backache and fatigue. Her mother has noticed
that she is becoming increasingly round-shouldered. On examination, she has a
smooth thoracic kyphosis. X-ray shows wedge-shaped vertebral bodies in the
thoracic spine.
32 Complications of fractures
A
B
C
D
E
F
compartment syndrome
osteoporosis
pneumothorax
ulnar nerve injury
pulmonary embolus
median nerve injury
G
H
I
J
K
L
delayed union
Sudecks atrophy
malunion
myositis ossificans
haemarthrosis
radial nerve injury
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 25-year-old man presents with a blue right arm with absent radial pulse and
painful passive finger extension following a supracondylar fracture of humerus.
A 65-year-old woman who falls on her outstretched arm has weakness in wrist
extension.
33 Management of fractures
A
B
C
D
E
F
G
skin traction
collar and cuff sling
broad arm sling
hip spica
gallows traction
internal fixation
complete bedrest and
immobilization
For each clinical scenario below suggest the most appropriate management. Each
option may be used only once.
1
A 24-year-old man presents with a swollen painful hand after falling over playing
squash. X-ray reveals a scaphoid fracture.
A 75-year-old woman presents to A&E with groin pain and inability to bear
weight following a fall. X-ray reveals an undisplaced fracture of the superior pubic
ramus.
Colles fracture
scapular fracture
posterior dislocation of shoulder
olecranon fracture
anterior dislocation of shoulder
scaphoid fracture
G
H
I
J
K
L
Galeazzi fracture
fracture of clavicle
Monteggia fracture
supracondylar fracture
fractured humeral shaft
Smiths fracture
For each clinical scenario below suggest the most likely injury that has resulted.
Each option may be used only once.
1
A 68-year-old woman presents with a fracture of the distal radius with dorsal
displacement of the distal fragment after a fall.
A 19-year-old rugby player falls on a backward stretched hand and presents with
loss of shoulder contour and absent sensation in the military badge area below the
shoulder.
35 Shoulder conditions
A
B
C
D
E
F
G
H
I
J
K
L
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 65-year-old woman presents with shoulder pain and restricted movement in all
directions. X-ray shows reduced joint space and subchondral sclerosis.
36 Knee conditions
A
B
C
D
E
F
genu varum
collateral ligament rupture
suprapatellar bursitis
Bakers cyst
prepatellar bursitis
meniscal tear
G
H
I
J
K
L
dislocation of patella
genu valgum
osteoarthritis
anterior cruciate ligament tear
meniscal cyst
OsgoodSchlatters disease
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 14-year-old girl successfully treated for rickets 3 years ago shows bow-legged
deformity.
A 16-year-old boy complains of a painful knee during exercise and a tender lump
over the tibial tuberosity.
A 50-year-old carpet layer presents with a swelling directly over the patella. The
joint feels stable and there is no effusion.
G
H
I
J
K
L
oral prednisolone
flucloxacillin benzylpenicillin i.v.
hydrocortisone i.v.
sulphasalazine
ibuprofen
methotrexate
For each clinical scenario below suggest the most appropriate management. Each
option may be used only once.
1
A 24-year-old man presented with lower back pain and stiffness that was worse in
the morning. He has developed a thoracic kyphosis and has a hyperextended neck.
A 64-year-old woman who has been successfully treated for acute gout requires
prophylactic medication.
38 Foot conditions
A
B
C
D
E
F
pes planus
plantar fasciitis
osteomyelitis
hallux rigidus
pes cavus
march fracture
G
H
I
J
K
L
claw toe
hammer toe
deltoid ligament injury
Mortons neuroma
osteochondroma
Achilles heel rupture
For each clinical scenario below give the most likely cause for the clinical findings.
Each option may be used only once.
1
A 32-year-old marathon runner presents with persistent pain over the dorsum of
the foot on weight-bearing.
A 62-year-old man presents with persistent pain over the left big toe. On examination there is swelling and decreased range of movement over the first
metatarsophalangeal joint.
A 24-year-old man presents with pain in his right heel that is worse in the morning. On examination there is pain on passive dorsiflexion of the toes and when
walking on tip-toes.
A 50-year-old woman complains of pain over the dorsal aspect of the PIP joint of
the second toe. On examination there is a flexion deformity of the PIP with
hyperextension at the DIP joint.
tibial nerve
common peroneal nerve
obturator nerve
femoral nerve
saphenous nerve
ilioinguinal nerve
G
H
I
J
K
iliohypogastric nerve
genitofemoral nerve
superior gluteal nerve
sciatic nerve
pudendal nerve
Choose the most likely location of the lesion that gives rise to the symptoms
below. Each option may be used only once.
1
A 75-year-old patient presents with a profound foot drop several days after a hip
hemiarthroplasty for a fractured neck of femur.
subscapular nerve
axillary nerve
median nerve
radial nerve
musculocutaneous nerve
ulnar nerve
G
H
I
J
K
C5, C6
suprascapular nerve
T1
long thoracic nerve
nerve to subclavius
Choose the most likely location of the lesion that gives rise to the symptoms
below. Each option may be used only once.
1
A 25-year-old man complains of anaesthesia over a patch on his outer upper arm
following anterior dislocation of the shoulder.
A young child presents to the orthopaedic clinic with claw hand and wasting of
the small muscles of the hand. There is sensory deficit to light touch along the
inner and upper forearm. The only medical history of note is that the child was
delivered in the breech position.
A 7-year-old is found to have numbness over the medial one and a half fingers
after suffering a supracondylar fracture of the humerus.
musculocutaneous nerve
axillary nerve
median nerve injury: wrist
suprascapular nerve
median nerve injury: elbow
ulnar nerve injury: wrist
G
H
I
J
K
L
Choose the most likely location of the lesion that gives rise to the symptoms
below. Each option may be used only once.
1
A 35-year-old patient is brought to A&E following a road traffic accident. She has
suffered multiple fractures to the humerus and forearm bones. On examination
there is an obvious wrist drop, loss of elbow extension and sensation loss over the
first dorsal web space.
A 30-year-old rugby player presents with winging of the scapula after suffering a
blow to the ribs underneath an outstretched arm.
EMQ answers 77
ANSWERS
27 Hand conditions
Answers: 1B, 2G, 3F, 4D
A 74-year-old man presents with inability to extend the ring finger. On
examination his ring finger is locked in flexion but can be released with
manipulation.
B
The finger flexor tendons usually glide smoothly under the A1 pulley of the hand.
If there is thickening of the flexor tendon, or if a nodule develops, the tendon
can be caught under the pulley thus locking the tendon. Forceful extension/
manipulation can release the tendon with transient discomfort. This condition is
known as trigger finger.
Management can be medical or surgical. Medical intervention involves corticosteroid injections into the flexor sheath. Surgical intervention involves surgical
release of the A1 pulley which can usually be performed under local anaesthesia.
A 42-year-old woman presents with a firm swelling over the dorsum of the
wrist. It has been fluctuating in size and causes discomfort when typing.
G A ganglion is a firm, smooth, cystic lesion that is closely associated with a joint or
tendon sheath. This patient presents with a lesion on the dorsum of the wrist
which is the most common site (related to scapholunate ligament of wrist). They
may cause significant anxiety due to fear of malignancy, so reassurance is an
important part of management. Treatment is by excision under general anaesthetic. The patient should be warned about the risk of recurrence.
A 36-year-old woman presents with pain over the radial aspect of the wrist.
On examination pain is elicited by forced adduction and flexion of the thumb.
F
an acute severe abducting force to the thumb. It is associated with ski injury
due to the position of the ski-pole strap across the palm which transmits the
force of injury to the thumb during a fall. With minor injuries conservative
measures and physiotherapy are often sufficient. If there is complete rupture
surgical intervention is indicated.
28 Arthritis
Answers: 1C, 2N, 3E, 4H, 5A
A 54-year-old woman presents to her GP with pain and swelling affecting
her fingers, wrists, knees and feet. On examination there are signs of ulnar
deviation and subluxation at the MCP joints. There are mild effusions over the
painful joints and they are warm on palpation. She suggests that the symptoms
are worse in the morning.
C
EMQ answers 79
A 22-year-old man presents with an acute arthritis of the left knee, dysuria
and bilateral conjunctivitis. He has recently suffered from gastroenteritis.
H Reiters disease involves a triad of urethritis, conjunctivitis and seronegative
arthritis. Joint symptoms may be the presenting complaint. It is often triggered by
an infection (e.g. a sexually transmitted disease or gastroenteritis). Cutaneous
manifestations include keratoderma blenorrhagica, circinate balanitis and mouth
ulcers. Enthesitis causing plantar fasciitis is also well recognized.
A 45-year-old woman presents with bilateral painful deformed distal
interphalangeal joints. Examination reveals discoloration and onycholysis
of the nails.
A Psoriatic arthritis is one of the seronegative spondyloarthritides. It is important to
remember that the skin manifestations may occur subsequent to joint involvement.
The patient in the question shows a typical presentation of distal interphalangeal
joint involvement with signs of nail dystrophy. Radiologically the affected joints
show central erosion rather than the juxta-articular involvement that is seen in
rheumatoid arthritis.
About 5 per cent of patients with psoriasis may present with marked deformity in
the fingers caused by severe periarticular osteolysis. This is known as arthritis
mutilans.
29 Joint pain
Answers: 1L, 2F, 3K, 4J, 5D
A 64-year-old patient who has recently been started on medication for hypertension presents with a very painful, hot, swollen metatarsophalangeal joint.
L
Bleeding into the joint (haemarthrosis) may occur in all patients but is more common in those with acquired/inherited disorders of coagulation like haemophilia.
Development of haemarthrosis is usually immediate (e.g following ligamentous
injury) whereas a serous effusion is usually delayed.
A 55-year-old man presents to A&E with fever and an exquisitely painful right
knee. On examination his right knee is red, hot and swollen. Purulent fluid is
aspirated from the joint.
K
D Polymyalgia rheumatica is associated with giant cell arteritis and is very rare under
the age of 50 years. Patients also often complain of fatigue and depression. It is
typically associated with a high ESR. Oral prednisolone is the treatment of choice.
EMQ answers 81
A 6-year-old boy presents with a pain in the hip and a limp. All movements at
the hip are limited. X-ray shows decrease in size of the femoral head with
patchy density.
M Perthes disease is osteochondritis of the femoral head and classically affects children in a younger age group compared to slipped upper femoral epiphysis (around
311years). It is around four times more common in males. The younger the
patient, the better the prognosis. In many cases, rest is sufficient treatment. In
severe disease, surgery may be indicated.
A 2-year-old girl presents to the orthopaedic clinic with a waddling gait. Her
mother says that there has been a delay in walking. On examination there is an
extra crease on the left thigh.
C
Congenital dislocation of the hip (CDH) is around six times more common in
females and is more common after breech delivery. The Ortolani test and Barlows
manouevre are performed to identify this condition which is bilateral in about a
third of cases. In Ortolanis test the examiner holds the babys thighs with the
thumbs placed medially and the fingers resting on the greater trochanters. The
examiner flexes the hips to 90 and gently abducts to almost 90. In CDH this
movement is difficult and if pressure is applied to the greater trochanter there is
an audible click as the dislocation reduces. Barlows test involves the examiner
grasping the upper thigh with the thumb placed in the groin and attempting to
lever the femoral head in and out of the acetabulum as he/she abducts and
adducts the thigh. Ultrasound screening is more commonly used now to diagnose
and monitor this condition.
An 80-year-old woman presents to A&E following a fall. On examination the
left hip is shortened, externally rotated and all movements are painful.
The classical deformity of the fractured neck of femur (NOF) is limb shortening
with external rotation of the leg. As a result of the fracture the pull of the iliopsoas twists the femur into external rotation rather than simply flexing the hip
joint. The pull of the short gluteal muscles shortens the leg. There may be particular tenderness over the anterior and lateral aspects of the hip joint.
NOF fractures can be broadly described as intracapsular or extracapsular. The former are more likely to disrupt the blood supply to the femoral head and can be
treated by cannulated screws or joint replacement if very displaced or if the
patient is elderly and needs to fully weight-bear immediately after surgery.
An 8-year-old boy presents to A&E with a marked limp and pain in the right
hip which resolves within 48 hours. X-rays show no abnormality at the hip or
other joint involvement. Bone scan 2 weeks later is also normal.
The patient must have a normal x-ray for the diagnosis to be made. This condition
is also known as irritable hip. Transient synovitis is a diagnosis of exclusion; i.e.
the diagnosis is made only when all other possible diagnoses are eliminated.
31 Back pain
Answers: 1K, 2G, 3J, 4C, 5D
A 22-year-old man complains of stiffness in the lower back and buttock
pain that is relieved by exercise. He also suffers from bouts of painful red eye.
ESR is raised. X-ray shows blurring of the upper vertebral rims of the lumbar
spine.
K
This mans buttock pain is caused by sacroiliitis. Blurring of the vertebral rims is an
early sign on x-ray, resulting from enthesitis at the insertion of intervertebral ligaments. Later, persistent enthesitis leads to the formation of bony spurs called syndesmophytes.
A 60-year-old woman presents with constant backache. ESR and serum calcium
are markedly elevated.
G Back pain is common in the elderly and the cause is often benign. However,
constant symptoms, raised ESR and raised serum calcium raises the suspicion of
underlying myeloma.
A 65-year-old man with osteoarthritis complains of back pain, worse on
walking, along with aching and heaviness in both legs that forces him to stop
walking. Pain is relieved slowly after rest or leaning forward.
J
EMQ answers 83
32 Complications of fractures
Answers: 1A, 2H, 3E, 4G, 5L
A 25-year-old man presents with a blue right arm with absent radial pulse and
painful passive finger extension following a supracondylar fracture of humerus.
A Fracture can lead to ischaemia in the distal limb by direct injury to the blood
vessel or by the effect of oedema increasing the pressure within the osteofascial
compartment which limits perfusion. In compartment syndrome, the increased
pressure can lead to profound ischaemia with necrosis of muscle and nerve tissue.
This is a surgical emergency requiring prompt decompression by open fasciotomy.
Once muscle tissue dies it is replaced by inelastic fibrous tissue giving rise to the
complication of Volkmanns ischaemic contracture.
A 40-year-old woman presents 5 weeks after a radial fracture with a painful
swollen hand. The hand is cold and cyanosed with heightened temperature
sensitivity.
H This condition is now known as complex regional pain syndrome type 1. The pain
and swelling is close to but not exactly at the area of injury. The skin may be
oedematous and there may be altered sweat production. Its aetiology is unknown.
A 70-year-old woman complains of right-sided pleuritic chest pain 10 days
after a fractured neck of femur.
E
G Absence of callus at the fracture site implies delayed union. Malunion is diagnosed
if the fracture heals with non-anatomical alignment.
A 65-year-old woman who falls on her outstretched arm has weakness in wrist
extension.
L
The radial nerve supplies motor innervation to the extensors of the wrist. Look out
for signs of radial nerve injury following fracture/dislocation of the elbow, fracture
of the humerus, shoulder dislocation and injury to the brachial plexus/axillary
region.
33 Management of fractures
Answers: 1I, 2J, 3F, 4B, 5H
A 24-year-old man presents with a swollen painful hand after falling over
playing squash. X-ray reveals a scaphoid fracture.
I
The wrist is held in dorsiflexion. A plaster cast from the wrist to above the
knuckle provides insufficient support. Internal fixation is sometimes required with
displaced/non-healing fractures.
A 75-year-old woman presents to A&E with groin pain and inability to bear
weight following a fall. X-ray reveals an undisplaced fracture of the superior
pubic ramus.
The pubic rami are not required for structural support when walking, so weightbearing should be encouraged once the patients pain has been suitably managed.
Bed rest is associated with morbidity and complications such as deep vein
thrombosis/pulmonary embolus and pressure sores and is not required in normally
mobile patients with a pubic ramus fracture.
A 65-year-old woman presents with a displaced extracapsular fractured neck
of femur.
The aim of a sling is to use the gravitational force of the arm/forearm to reduce
and/or hold the fracture. A collar and cuff sling permits gravity to help realign a
humeral fracture, whereas a broad arm sling is more useful for helping to realign a
fractured clavicle.
A 75-year-old woman presents to A&E with a displaced Colles fracture.
EMQ answers 85
the palm of the hand with the wrist slightly flexed and in mild ulnar deviation.
An x-ray after reduction should be obtained to ensure that there is a satisfactory
position.
The anatomical snuff box (ASB) is a triangular depression best seen when the
thumb is extended. It is bounded anteriorly by the tendons of the abductor pollicis
longus and extensor pollicis brevis and posteriorly by the tendon of the extensor
pollicis longus. The scaphoid and trapezium lie at the base of the ASB. The radial
styloid process and the base of the first metacarpal can be felt proximally and
distally to the floor respectively. The radial artery and a superficial branch of the
radial nerve cross the ASB.
Pain and swelling at the ASB following injury to the arm/hand suggests fracture
of the scaphoid. If there is high index of suspicion for a fractured scaphoid but
no positive x-ray findings, a plaster cast may be applied and an x-ray repeated
2 weeks later (the fracture may become more clear later). Alternatively, bone
scans or MRI scans will reveal the injury.
A 68-year-old woman presents with a fracture of the distal radius with dorsal
displacement of the distal fragment after a fall.
This injury is more common in children following a fall on the outstretched hand.
It is imperative to look for any signs of damage to the brachial artery. The elbow
should be kept extended to avoid arterial damage. Displaced fractures are surgical
emergencies and treated by reduction under general anaesthesia.
A 19-year-old rugby player falls on a backward stretched hand and presents
with loss of shoulder contour and absent sensation in the military badge area
below the shoulder.
The loss of sensation results from damage to the axillary nerve. On x-ray the
humeral head lies anterior and inferior to the glenoid. The shoulder can be
reduced with the Kochers manoeuvre. The elbow is flexed to 90 and traction
applied. The arm is slowly externally rotated to about 90, brought across the chest
and then finally internally rotated.
A 40-year-old woman presents after a fall on an outstretched hand, with pain
in the upper arm and a wrist drop.
The radial nerve is susceptible to injury with fracture of the humeral shaft as it
winds around the humerus in the spiral groove.
35 Shoulder conditions
Answers: 1G, 2E, 3A, 4K, 5D
A 21-year-old woman presents with a very painful shoulder locked in adduction and internal rotation following an epileptic fit.
G Posterior dislocation is extremely rare but should always be considered in the
epileptic patient with a painful shoulder post-seizure. On examination the coracoid process may be prominent and the humeral head felt posteriorly. The arm is
held in the adducted, internally rotated position. A lateral film is essential to spot
the posterior subluxation.
A 55-year-old man complains of shoulder pain aggravated in abduction of the
arm between 60 and 120.
E
This patient is describing a painful arc syndrome. The pain of supraspinatus tendonitis can be elicited if the examiner elevates an internally rotated arm causing
the supraspinatus tendon to impinge against the anterior inferior acromion. This
pain is reduced/alleviated if the test is repeated after injecting local anaesthetic
into the subacromial space.
Treatment includes the use of physiotherapy and patient education with respect to
particular arm movements/activities. Corticosteroid/local anaesthetic injections are
useful in the acute setting. Surgery is often necessary to arthroscopically increase
the space for the tendon to move.
A 30-year-old bodybuilder presents with a painful shoulder after weightlifting.
Flexing his elbow reveals a prominent lump in the upper arm.
A This injury occurs after lifting/pulling activity. Good function usually returns without the need for surgery.
EMQ answers 87
D Reduced joint space, subchondral sclerosis, subchondral cysts and osteophytes are
radiological features suggestive of osteoarthritis.
36 Knee conditions
Answers: 1F, 2J, 3A, 4L, 5E
A 22-year-old figure-skater presents with a painful locked knee with limited
extension following a twisting injury.
F
Meniscal tears usually result from a twisting injury. The displaced torn portion can
become jammed between femur and tibia, resulting in locking. The medial meniscus is closely associated with the medial collateral ligament, so it is important to
look out for dual pathology.
A 24-year-old footballer presents with a painful knee after landing awkwardly
and twisting his knee after a header. With the quadriceps relaxed, there is
excessive anterior glide of the tibia on the femur.
With the knee flexed at 90, anterior glide of the tibia on the femur should only
be about 0.5 cm. Excessive glide anteriorly implies anterior cruciate ligament
damage; excessive glide posteriorly implies posterior cruciate ligament damage.
A 14-year-old girl successfully treated for rickets 3 years ago shows bowlegged deformity.
OsgoodSchlatters disease is more common in older children. Pain is felt particularly on direct palpation of the tibial tuberosity and when straight leg raising
against resistance. The presence of a lump over the tibial tuberosity is diagnostic.
Spontaneous recovery is usual but it is advisable to reduce sporting activity
during this time.
A 50-year-old carpet layer presents with a swelling directly over the patella.
The joint feels stable and there is no effusion.
E
EMQ answers 89
38 Foot conditions
Answers: 1F, 2D, 3B, 4H
A 32-year-old marathon runner presents with persistent pain over the dorsum
of the foot on weight-bearing.
F
A march fracture is the term used to describe a metatarsal stress fracture of the
foot caused by excessive repetitive injury. It is therefore more common in athletes.
Treatment is rest (an air-cast boot can be provided to reduce weight-bearing over
the fracture site). Stress fractures are not always evident on plain radiographs, so
the diagnosis may often be based on clinical examination alone for the first
23 weeks. MRI scans and bone scans are very helpful.
A 62-year-old man presents with persistent pain over the left big toe. On
examination there is swelling and decreased range of movement over the first
metatarsophalangeal joint.
A 50-year-old woman complains of pain over the dorsal aspect of the PIP joint
of the second toe. On examination there is a flexion deformity of the PIP with
hyperextension at the DIP joint.
H A hammer toe involves flexion of the proximal interphalangeal joint (PIP) and
extension at the metatarsophalangeal joint and distal interphalangeal joint (DIP).
Indication for surgery is failure of conservative measures (e.g. strapping to control
pain). There are a number of options including arthrodesis of the PIP joint and
flexor/extensor tenotomy.
The common peroneal nerve is susceptible to injury as it winds around the neck of
the fibula. Injury results in foot drop (weakness of dorsiflexion and eversion).
Sensation loss affects the area of skin over the anterolateral lower leg stretching
to the dorsum of the foot (except for an area on the lateral side of the foot supplied by the sural nerve).
A 75-year-old patient presents with a profound foot drop several days after a
hip hemiarthroplasty for a fractured neck of femur.
The sciatic nerve is at risk of injury during the posterior approach to the hip joint.
Injury results in a profound foot drop with loss of all movement below the knee
and paralysis of hamstrings.
A 38-year-old woman complains of sensation loss over the anteromedial aspect
of the lower leg following varicose vein surgery.
The saphenous nerve arises from the posterior division of the femoral nerve and
lies in close proximity to the long saphenous vein. It is therefore at risk of injury
during long saphenous vein stripping surgery. It provides sensation to the anteromedial lower leg.
A 36-year-old man is brought to A&E after suffering penetrating trauma to
the right popliteal fossa. On examination there is loss of active plantar flexion
and loss of sensation over the sole of the foot.
A The tibial nerve arises from the sciatic nerve just above the apex of the popliteal
fossa. It passes in the midline of the popliteal fossa superficial to the popliteal vein
and artery. It supplies sensation to the sole of the foot and motor supply to the
flexors of the foot.
EMQ answers 91
The axillary nerve is related to the medial aspect of the surgical neck of the
humerus and is at risk of injury following fracture at this level or anterior dislocation of the shoulder. It is important to check the integrity of the nerve after anterior dislocation of the shoulder and to re-check the nerve status after reduction. It
provides motor branches to the deltoid muscle and teres minor.
A 63-year-old man is found to have weakness of thumb abduction following
carpal tunnel release surgery.
The median nerve motor supply to the small muscles of the hand can be remembered by the mnemonic LOAF (lateral two lumbricals, opponens pollicis, abductor
pollicis brevis, and flexor pollicis brevis). The recurrent motor branch of the median
nerve is at risk of injury during carpal tunnel surgery.
A young child presents to the orthopaedic clinic with claw hand and wasting of
the small muscles of the hand. There is sensory deficit to light touch along the
inner and upper forearm. The only medical history of note is that the child was
delivered in the breech position.
This is a presentation of Klumpkes palsy which has resulted from upward traction
on the arm during breech delivery causing injury to T1. Traction to the sympathetic chain can also give rise to an ipsilateral Horners syndrome. Clawing results
from the unopposed action of the long flexors.
A 7-year-old is found to have numbness over the medial one and a half fingers
after suffering a supracondylar fracture of the humerus.
Injury of the ulnar nerve at the wrist gives rise to a distinctive claw hand. This is
because paralysis of the lumbricals provides hyperextension of the metacarpals
and paralysis of the interossei leads to flexion at the interphalangeal joints.
Sensory deficit affects the little finger and medial half of the ring finger.
Paradoxically a higher lesion at the level of the elbow, in this scenario, causes less
clawing of the hand due to paralysis of the ulnar half of flexor digitorum profundus (unopposed flexion causes the clawing).
Clinical examination is useful to reveal the level of radial nerve injury. An injury at
the level of the axilla is associated with loss of elbow extension along with the
wrist drop and radial nerve sensory loss over the first dorsal web space.
With an injury at the level of the humerus shaft, elbow extension is preserved. An
injury at the level of the wrist is associated with weakness in finger/wrist extension, but there is minimal wrist drop as the posterior interosseous nerve providing
motor supply branches off above the level of the wrist.
A 45-year-old patient is brought to A&E after being assaulted. There is significant bruising over the right upper limb. On examination there is loss of forearm pronation and the hand is noted to deviate to the ulnar side when flexing
the wrist.
Median nerve injury at the level of the elbow is associated with motor loss of the
forearm pronators, and weakness of the forearm flexors and muscles of the thenar
eminence. Sensation loss occurs over the radial three and a half fingers. An injury
at wrist level spares the long flexors and sensation over the palmar aspect of the
thenar eminence is spared (palmar cutaneous branch given off above wrist level).
A 30-year-old rugby player presents with winging of the scapula after suffering a blow to the ribs underneath an outstretched arm.
The long thoracic nerve supplies the serratus anterior which allows protraction
of the shoulder. It is particularly at risk during breast/axillary surgery. The winging
of the scapula deformity is best exemplified when the patient is pushing against
a wall.
SECTION 3: EMQS IN
VASCULAR SURGERY
42
43
44
45
QUESTIONS
42 Management of abdominal aortic aneurysm
A elective infrarenal endovascular
stenting
B open aortoaortic repair
C open aortobiiliac repair
D ultrasound scan
E abdominal contrast CT scan
F
G
H
I
J
For each clinical scenario below, suggest the most appropriate management. Each
option may be used only once.
1
A 75-year-old male with a long history of lumbar spinal and hip arthritis presents
with sudden severe back pain, BP 100/50 mmHg, pulse 105/min.
A 78-year-old woman presents 3 years after elective aortic aneurysm repair with a
microcytic anaemia of unknown origin.
A 70-year-old male presents with a 1-week history of mid-back pain and right leg
claudication at 150 yards. Imaging shows enlarged dual lumen descending thoracic and abdominal aorta. He is known to be hypertensive.
heparin i.v.
femoropopliteal bypass
conservative management
sympathectomy
femoral-femoral crossover graft
thrombolysis
G Fogarty catheter
H percutaneous transluminal
angioplasty
I aortofemoral bypass
J above-knee amputation
K below-knee amputation
For each clinical scenario below, suggest the most appropriate management. Each
option may be used only once.
1
A 75-year-old smoker presents with severe rest pain in her right leg. On examination there is advanced gangrene and cellulitis of the right foot with absent distal
pulses. Angiography shows occluded crural vessels to the ankle.
A 73-year-old overweight smoker presents with pain in his legs after walking half
a mile, which is relieved immediately by rest. Ankle brachial pressure index is 0.8.
A 62-year-old man presents with severe bilateral pain in the legs. He is known to
suffer from impotence and buttock claudication. Femoral pulses are weak.
Arteriography shows long occlusions on both common iliac arteries with good distal run-off. Angioplasty, though initially promising, proved unsuccessful.
A 74-year-old man with atrial fibrillation who suffered a stroke a week ago presents with an ischaemic cold foot. Duplex ultrasonography reveals acute occlusion
of the popliteal artery.
G
H
I
J
compartment syndrome
retroperitoneal haematoma
sciatic nerve injury
acute ischaemic cerebrovascular
accident
K artery of Adamkiewicz injury
For each clinical scenario below, identify the most comon complication. Each
option may be used only once.
1
A 64-year-old man is unable to dorsiflex his right foot 24 hours after revascularization of acutely ischaemic foot on that side.
A 65-year-old man presents with loss of power in both legs after aortic aneurysm
repair.
A 57-year-old man is referred by the cardiologists with cool distal peripheries following repeated transfemoral catheterization of coronary arteries in the presence
of aortic aneurysm.
carotidcarotid bypass
carotid endarterectomy
axillofemoral bypass
antiplatelet agent: statin
watch and wait
F
G
H
I
J
For each clinical scenario below, identify the most appropriate treatment. Each
option may be used only once.
1
A 75-year-old patient with significant coronary artery disease presents with symptomatic restenosis of the right internal carotid artery. The anaesthetist feels that
he is high risk for further surgery.
A 68-year-old man who initially presented to the physicians with amaurosis fugax
is found to have 82 per cent left internal carotid artery stenosis.
A 58-year-old patient is found to have 50 per cent internal carotid artery stenosis.
He is asymptomatic.
A 65-year-old woman has recently taken up tennis to stay fit. She reports episodes
of syncope during play.
ANSWERS
42 Management of abdominal aortic aneurysm
Answers: 1E, 2A, 3C, 4J, 5I
A 75-year-old male with a long history of lumbar spinal and hip arthritis presents with sudden severe back pain, BP 100/50 mmHg, pulse 105/min.
E
Abdominal aortic aneurysms are asymptomatic in most patients and often found
incidentally. Sudden-onset severe back pain could prove an important early warning of an impending potentially catastrophic complication especially if new or different. Tachycardia and hypotension may suggest a contained leak. Emergency
intravenous contrast CT is the investigation of choice in this setting.
An 82-year-old is found to have an uncomplicated 7.5-cm AAA on ultrasound as
an incidental finding. He has had a previous emergency Hartmanns procedure for
septic peritonitis secondary to benign diverticular perforation, 5 years earlier.
A Surgery is recommended for aortic aneurysms greater than 5.5 cm diameter. This
may be performed using the open or endovascular technique. The latter is associated with lower perioperative morbidity and mortality and may be preferable in
elderly patients with significant systemic comorbidity and for the potentially hostile abdomen.
A 64-year-old man presents with an asymptomatic juxtarenal abdominal aortic
aneurysm measuring 6.5 cm in diameter. The left and right common iliac arteries
measure 1.5 cm and 3.5 cm respectively. He has no other past medical history.
C
Aortoenteric fistula (AEF) is an uncommon often late complication of open repair and
may present as unexplained anaemia. Aortoenteric fistula is an uncommon catastrophic communication between the aorta and the gastrointestinal tract. Primary
AEF is very rare with 200 reported cases. Secondary AEF is a more common late
complication of open AAA repairs (about 1 per cent). The overlying duodenum is
involved in 80 per cent of cases. The initial herald bleed presenting as melaena or
haematochezia, with minimal haemodynamic consequence, is followed hours or days
later by catastrophic gastrointestinal bleed. A high index of suspicion is vital.
EMQ answers 99
Endoscopy is the procedure of choice and is diagnostic in 90 per cent of cases. CT,
MRI and transluminal angiography may also be useful. Surgery is mandatory and
associated with 6090 per cent mortality, compared to 100 per cent if untreated.
A 70-year-old male presents with a 1-week history of mid-back pain and right
leg claudication at 150 yards. Imaging shows enlarged dual lumen descending
thoracic and abdominal aorta. He is known to be hypertensive.
I
Aortic dissection (AD) is more common than aortic rupture and, if untreated, mortality increases by 1 per cent every hour for the first 48 hours. Type A dissection
involves the ascending aorta and aortic arch. Type B originates in the descending
thoracic or thoracoabdominal aorta and may involve the arch but not the ascending aorta. AD may present with tearing acute midsternal chest pain (ascending) or
interscapular back pain (descending). Propagation may present as migratory pain
and peripheral and visceral ischaemia as branches are involved.
CT and increasingly MR angiography is the investigation of choice.
Transoesophageal echocardiography is a reliable second choice. Emergency surgery
is indicated for acute type A dissection. Uncomplicated type B dissection is best
managed medically with rapid control of blood pressure using sodium nitroprusside and beta-blockers (e.g. labetalol).
Angioplastic or surgical revascularization is unlikely to succeed where crural vessels are occluded below the ankle. It is especially important to adequately counsel
the patient for such as a measure. Forefoot amputation will not be advisable in a
non-revascularized foot. A below-knee amputation may represent the best option
to avert the risk of systemic sepsis and restore quality of life.
A 73-year-old overweight smoker presents with pain in his legs after walking half
a mile, which is relieved immediately by rest. Ankle brachial pressure index is 0.8.
Claudication distance (distance travelled before he gets pain) of 500 yards may be
considered reasonable for this patient, obviating invasive treatment in the first
instance. Ankle brachial pressure index of above 0.9 is normal. Patients with claudication but no rest pain usually have a value that is between 0.6 and 0.9. A value
below 0.6 is associated with rest pain and critical ischaemia. Conservative management consists of stopping smoking, taking up physical exercising such as walking and weight reduction. Medical intervention includes the treatment of diabetes,
hypertension and hyperlipidaemia. Daily low-dose aspirin is indicated.
A 62-year-old man presents with severe bilateral pain in the legs. He is known
to suffer from impotence and buttock claudication. Femoral pulses are weak.
Arteriography shows long occlusions on both common iliac arteries with good
distal run-off. Angioplasty, though initially promising, proved unsuccessful.
I
The distal aorta bifurcates into the two common iliac arteries (median sacral
branch is also given off). The common iliac artery divides to form the external and
internal iliac arteries. The external iliac artery passes under the inguinal ligament
to become the femoral artery. Angioplasty and stenting of the iliac arteries is the
first option and is successful in most cases. Otherwise, as in this case, an aortobifemoral bypass should restore appropriate axial flow to both legs.
A 65-year-old man complains of left calf claudication at 50 m. Angiography
reveals a 10-cm stenosis of the superficial femoral artery.
H The superficial femoral artery becomes the popliteal artery in the popliteal fossa.
Percutaneous transluminal angioplasty is the treatment of choice for this scenario
where there is significant stenotic or occlusive disease of the superficial femoral artery.
A 74-year-old man with atrial fibrillation who suffered a stroke a week ago
presents with an ischaemic cold foot. Duplex ultrasonography reveals acute
occlusion of the popliteal artery.
G With acute ischaemia secondary to embolism, surgical embolectomy with Fogarty
catheter is indicated. Intra-arterial local thrombolysis involves the use of thrombolytics like streptokinase/t-PA. Thrombolysis would be contraindicated in this scenario due to his recent history of stroke.
syndrome is limb-threatening and occurs when perfusion pressure drops below tissue
pressure in a confined anatomical space. Consequently, perfusion and tissue oxygenation cease as the contents of the compartment become increasingly ischaemic. The
limb is swollen, tender and painful at rest or with passive movement progressing to
loss of sensation, paraesthesia and paralysis. Fasciotomy is both prophylactic and
therapeutic. The former is advisable following prolonged severe ischaemia.
A 72-year-old woman presents with an erythematous tender groin lump which
suddenly appeared 3 years after aortofemoral bypass.
C
Low virulence prosthetic graft infection may present many years after the initial
operative procedure. A recent review reported 7 per cent incidence of vascular
graft infection in 410 patients (Vasc Endov Surg 2005;39(6):115). Misdiagnosis as
strangulated groin hernia may present the surgeon with an unpleasant surprise for
which he may be unprepared.
A 65-year-old man presents with loss of power in both legs after aortic
aneurysm repair.
D Cerebrovascular accident (stroke) is the third leading cause of death in the UK.
Eighty per cent of strokes are ischaemic, and of these 80 per cent are related to
the carotid artery distribution. Atherosclerotic disease is responsible for more than
90 per cent of carotid ischaemic events. Treatment options are medical, surgical
and endovascular. All stand to benefit from cardiovascular risk reduction with
antiplatelet agents (aspirin, clopidogrel), statins, weight reduction, control of
hypertension and diabetes, smoking cessation and active lifestyle.
A 65-year-old woman has recently taken up tennis to stay fit. She reports
episodes of syncope during play.
I
Subclavian steal syndrome occurs when, as a result of proximal subclavian or brachiocephalic artery occlusion, there is retrograde diverted flow, via the vertebral
artery to the distal subclavian, causing cerebral or brainstem ischaemia. The
patients are usually asymptomatic until increased upper limb muscular activity
makes a greater demand (steal) on the brain circulation causing transient
ischaemia, often presenting as vertigo or syncope. Absence of a pulse and differential upper limb hypotension add to the diagnosis which can be confirmed on
duplex ultrasound, transluminal, CT or MR angiography. The occluded subclavian
origin may be revascularized by angioplasty/stenting or surgical bypass.
SECTION 4: EMQS IN
UROLOGY
46
47
48
49
50
51
52
53
54
Haematuria
Testicular conditions
Bladder outlet obstruction
Management of prostate cancer
Urinary incontinence (diagnosis/management)
Management of renal stones
Lumps in the groin
Urological imaging/intervention
Renal masses/tumours
EMQs in urology
QUESTIONS
46 Haematuria
A
B
C
D
E
Wilms tumour
neuroblastoma
renal cell carcinoma
fibroepithelial polyp
squamous cell carcinoma of the
bladder
F
G
H
I
J
For each clinical scenario below, suggest the most likely cause for the haematuria.
Each option may be used only once.
1
A 75-year-old woman has had a UTI treated but has persistent microscopic
haematuria seen on urine dipstick. Shes not worried but her GP refers her to the
one-stop haematuria clinic.
A 50-year-old man with weight loss, loss of appetite and shortness of breath has
recently noticed a left-sided varicocoele which does not disappear on lying supine.
A 35-year-old man with new-onset hypertension is admitted to hospital for investigation. His creatinine is 134 mol/L. After imaging he is advised to tell his
brother to undergo family screening and genetic counselling.
A 29-year-old man from Egypt presents with weight loss and haematuria.
Pseudotubercles and nodules seen on cystoscopy are biopsied.
47 Testicular conditions
A
B
C
D
E
F
varicocoele
chronic orchitis
ectopic testis
hydrocoele
non-seminomatous testicular cancer
seminoma
G
H
I
J
K
epididymal cyst
indirect inguinal hernia
acute epididymo-orchitis
testicular atrophy
testicular torsion
For each clinical scenario below, suggest the most likely diagnosis. Each option
may be used only once.
1
A 52-year-old man presents with a testicular swelling that has increased in size
gradually over a period of years. On examination the swelling transilluminates and
the testis cannot be felt separate from the swelling.
A 40-year-old man complains of severe pain and swelling over the last 48 hours in
his right scrotum. Testis and epididymis are very tender. He reports that he has had
unprotected intercourse recently.
A 20-year-old man with a history of undescended testes presents with weight loss
and a hard painless testicular lump.
A 9-year-old boy wakes at night crying from severe pain in the testis associated
with vomiting.
A 45-year-old man presents with a left-sided fluctuant scrotal swelling. On standing the swelling worsens.
phimosis
urethral stricture
pregnancy
prostate cancer
benign prostatic hypertrophy
clot retention
G
H
I
J
K
pelvic mass
bladder stones
urethral diverticula
urethral tumour
bladder tumour
For each clinical scenario below, suggest the most likely cause for bladder outlet
obstruction. Each option may be used only once.
1
A 58-year-old woman is due to undergo hysterectomy. She has chronic renal failure.
A 35-year-old man complains of difficulty passing urine. He has a history of multiple hospital admissions as a child for recurrent urine infections. He had bilateral
vesico-ureteric reflux for which he required repeated catheterization.
radical prostatectomy
bilateral orchidectomy
transurethral resection of prostate
watch and wait
radiotherapy
bone scan and dexamethasone
G anti-androgen medication
H luteinizing hormone releasing
hormone analogue
I long-term catheter and hospice
J family screening
K repeat PSA
For each clinical scenario below, suggest the most likely course of management.
Each option may be used only once.
1
A 66-year-old man has recently had a routine blood screen and is reported to have
an elevated PSA of 5.5 ng/mL. He is otherwise asymptomatic.
A 34-year-old man attends your clinic reporting that his twin brother has been
diagnosed with prostate cancer.
A 73-year-old man with prostate cancer attends your clinic complaining of newonset back pain.
A 52-year-old man is diagnosed with prostate cancer and staging confirms the
absence of secondary spread of disease.
F
G
H
I
J
K
DMSA
intravenous urogram
MAG3 scan
urethrogram
pelvic floor exercises
bladder augmentation
For each clinical scenario below, suggest the most suitable investigation/
management. Each option may be used only once.
1
A 35-year-old woman presents 2 years after the birth of her child with urinary
leakage on coughing, standing and sneezing.
A 25-year-old man presents with slowing of his urinary flow and terminal urethral
dribbling. He has a past history of a treated sexually transmitted disease.
A 75-year-old woman presents with recent onset of severe urinary urgency and
bladder pain. Urinary dipstick shows no nitrates, protein 1 and blood 2.
An 80-year-old man presents to the urology clinic with poor flow, frequency and
nocturia. He is noted to have an elevated creatinine.
A 40-year-old woman who has had two previous colposuspensions for urinary
incontinence now complains of mixed urge and stress leakage.
percutaneous nephrolithotomy
(PCNL)
G embolization
H nephrostomy
I ultrasound kidneys
J intravenous antibiotics
K retrograde ureteric stenting
For each clinical scenario below, suggest the most appropriate management
option. Each option may be used only once.
1
A 40-year-old man has had a PCNL to treat a renal 2.5-cm stone. At the end of
the procedure there is gross bleeding from the nephrostomy track. Nephrostomy
tamponade fails to stop the bleeding.
A 50-year-old woman with diabetes presents with severe left loin pain, pyrexia,
tachycardia and a white cell count of 24 000. Intravenous urogram shows no function on the initial 10-minute film.
A 37-year-old man presents with left renal colic. CT urogram shows a 5-mm stone
in the lower third of the left ureter with moderate hydronephrosis.
A 27-year-old man presents with severe loin pain. Plain x-ray shows a staghorn
calculus.
maldescended testis
femoral aneurysm
hydrocoele
lipoma of the cord
inguinal hernia
psoas abscess
G
H
I
J
K
varicocoele
seminoma
scrotal carcinoma
saphena varix
inguinal lymphadenopathy
For each of the clinical scenarios below, give the most likely cause for the clinical
findings. Each option may be used only once.
1
An incidental lump is found during inguinal hernia repair. It is benign and left
alone.
A new significant groin lump is found in a 9-year-old boy who had previously
undergone unsuccessful laparoscopy for undescended testis.
An 80-year-old man has been attending his GP for 3 years with an enlarging
right-sided scrotal mass which disappears on lying flat but worsens during the day.
The GP cannot get above the mass, nor does it transilluminate.
A 69-year-old woman with right leg pain is diagnosed with a deep vein thrombosis on Doppler investigation. On examination there are firm rubbery matted masses
in both groins.
53 Urological imaging/intervention
A transurethral resection of the
prostate
B retrograde ureterogram
C nephrostomy
D micturating cysto-urethrogram
E ultrasound of urinary tract
F intravenous urogram (IVU)
G frusemide/furosemide
H high-intensity frequency ultrasound
(HIFU) prostate ablation
I radical prostatectomy
J nephrocystourethrectomy and ileal
conduit formation
K active surveillance
For each clinical scenario below, suggest the most suitable next step. Each option
may be used only once.
1
An 83-year-old man with a PSA of 10 ng/mL and positive TRUS biopsy results
denies lower urinary tract symptoms. He does not want any surgical intervention.
A 45-year-old man has raised PSA of 29 ng/mL and positive TRUS biopsy results.
His brother died of prostate cancer aged 60 years.
A 30-year-old man with a history of renal stones has been on a business trip and
taken diclofenac and codeine throughout his meetings. He returns to attend A&E
with further pain.
54 Renal masses/tumours
A
B
C
D
E
F
lymphoma
polycystic kidney
simple cyst
sarcoma
adrenal mass
renal abscess
G
H
I
J
K
staghorn calculus
perirenal haematoma
squamous cell carcinoma
medullary sponge kidney
renal cell carcinoma
For each clinical scenario below, suggest the most likely cause for the renal mass.
Each option may be used only once.
1
A 23-year-old man attends A&E having fallen off a motorbike at 30 miles per
hour. He presents with an expanding left loin mass, bruising and haematuria.
ANSWERS
46 Haematuria
Answers: 1J, 2C, 3F, 4H, 5E
A 75-year-old woman has had a UTI treated but has persistent microscopic
haematuria seen on urine dipstick. Shes not worried but her GP refers her to
the one-stop haematuria clinic.
J
The classic triad of haematuria, loin pain and a palpable abdominal mass is found
in fewer than 20 per cent of those presenting with renal cell carcinoma.
In EMQs, look out for a coexisting paraneoplastic syndrome such as anaemia,
polycythaemia (due to excess erythropoeitin secretion) or hypercalcaemia (due to
PTH-related peptide secretion) that can occur in up to a third of patients.
Contrast CT will show the macroscopic features of the RCC as well as any further
liver or lung cannonball metastases. Solitary metastases can be excised and longterm survival is not uncommon.
RCC and testicular teratomas show a propensity for the development of solitary
pulmonary metastases. Treatment in absence of distant metastases is by radical
(open or laparoscopic) nephrectomy.
Five per cent of renal cell carcinomas are associated with direct tumour extension
into the inferior vena cava (IVC), and possibly the right atrium, in which case
thrombectomy is also combined with the nephrectomy. The infradiaphragmatic
Polycystic kidney disease occurs via autosomal dominant inheritance usually presenting in the fourth decade with loin pain and/or haematuria as a result of
haemorrhage into a cyst. Other symptoms/signs include abdominal discomfort due
to local pressure effects, hypertension or symptoms of chronic renal failure.
Family members are routinely screened and are thus diagnosed at a preclinical
stage by ultrasound imaging of the kidneys. Autosomal dominant PCKD is the
most common inherited disorder leading to renal failure due to replacement of the
substance of the kidney by cysts. Cysts may be found in the liver (30 per cent),
spleen (15 per cent) and pancreas (10 per cent).
PCKD accounts for about 10 per cent of patients receiving renal replacement therapy,
and a significant proportion of these will undergo renal transplantation.
An 18-year-old is travelling in the Australian outback during his gap year. He
returns to London to run the marathon which he does successfully. The next
day he attends A&E concerned about his dark red urine. He is otherwise completely asymptomatic but is admitted to hospital.
Schistosomiasis (bilharzia) has affected dwellers of the Nile valley for centuries.
The trematode penetrates the skin and flourishes in the liver. Eventually, a male
and female pair make their way to the inferior mesenteric vein and reach the
vesical venous plexus through the portosystemic anastomotic channels. The female
lays ova in the bladder. Cystoscopic examination may reveal bilharzias pseudotubercles and bilharzias nodules and biopsies of scanty patches can confirm the
diagnosis. Schistosomiasis of the bladder which has been neglected for years can
result in squamous cell carcinoma as a result of metaplasia.
47 Testicular conditions
Answers: 1D, 2I, 3E, 4K, 5A
A 52-year-old man presents with a testicular swelling that has increased in
size gradually over a period of years. On examination the swelling transilluminates and the testis cannot be felt separate from the swelling.
D A hydrocoele is a collection of fluid in the tunica vaginalis. As the fluid of the
hydrocoele surrounds the body of the testis, the underlying testis is impalpable.
Primary hydrocoele is idiopathic. Secondary hydrocoele occurs secondary to
trauma, tumour and infection. Aspiration is discouraged unless malignancy has
been ruled out. Surgical excision is by either Jaboulays or Lords procedure.
A 40-year-old man complains of severe pain and swelling over the last 48
hours in his right scrotum. Testis and epididymis are very tender. He reports
that he has had unprotected intercourse recently.
I
The onset of symptoms here are more insidious in nature than in acute torsion.
There may be signs of urinary tract infection (i.e. frequency and dysuria).
Chlamydia and other sources of sexually transmitted infections are more common
in younger men whereas bacteria such as Escherichia coli are more common in
older men. Symptoms include dysuria, fever, throbbing constant pain and tender
swollen epididymis. Antibiotic therapy is the treatment of choice. Occasionally surgical exploration may be necessary if there is doubt about the diagnosis.
A 20-year-old man with a history of undescended testes presents with weight
loss and a hard painless testicular lump.
Seminomas are the more common of the germ cell tumours. They usually present
between the age of 30 and 40 years, whereas non-seminomatous testicular cancers commonly present earlier (2030 years). Undescended testes are an important
risk factor for testicular tumours.
The most common presentation is of a palpable scrotal mass/scrotal pain. Less
common presentations include gynaecomastia, reduced libido and infertility
(tumour secreting hormones).
Assessment includes chest x-ray to identify cannonball pulmonary metastases,
tumour markers (alpha-fetoprotein and beta-HCG used to monitor germ cell
tumours), ultrasound and full staging CT once diagnosis is confirmed. Note that
40 per cent of seminomas classically do not produce AFP or -HCG.
Inguinal-approach orchidectomy with early clamping of the spermatic cord vessels
(preventing tumour dissemination during mobilization of the testis) is the surgical
treatment of choice. The spermatic cord is ligated at the deep inguinal ring and
the structures below are removed. Patients with evidence of extratesticular disease
on CT staging receive chemoradiotherapy with good response.
A 9-year-old boy wakes at night crying from severe pain in the testis
associated with vomiting.
K
Haematuria is a common cause of urinary retention. In this case the bladder outlet
obstruction is a result of the urethra being blocked by a residual clot from the
operation or from rebleeding. Patients with persistent postoperative bleeding
require catheterization with three-way irrigation to prevent obstructing bladder
outflow. The irrigation fluid is glycine. This is used to avoid TUR syndrome.
An 84-year-old man complains of difficulty passing urine, nocturia, hesitancy
and terminal dribbling. His PSA is normal for his age.
In young and middle-aged men, renal calculi are the most common cause of at
least temporary urinary obstruction. After the age of 60, urinary obstruction is
most common in men secondary to prostatic hypertrophy; prostate cancer
accounts for occasional cases. Symptoms of prostatism are poor flow, feeling of
incomplete emptying and hesitancy. In addition, patients may or may not complain of frequency, urgency, dribbling, decrease in voiding stream, and the need to
double void (pis-a-deux).
Urodynamic studies are useful. A flow-rate study with a voided volume of 200 mL
or more can be used; Qmax (maximum urinary flow rate) of less than 10 mL/s indicates bladder outlet obstruction.
Ultrasound scan of the abdomen measures post-micturition residual bladder
volume. A residual volume of more than 100 mL suggests chronic urinary retention. A transrectal ultrasound scan of the prostate confirms BPH and if a mass
lesion is seen, fine-needle aspiration for cytology or Tru-cut biopsy can be
performed.
Significant BPH can be treated by transurethral resection of prostate. A resectoscope is inserted during cystoscopy and prostatic chippings sent for histological
confirmation of diagnosis. Complications of the procedure include infection,
haemorrhage, clot retention urethral stricture, incontinence, retrograde ejaculation, impotence and transurethral syndrome. The latter syndrome is caused by
excessive absorption of glycine irrigation fluid. The resultant fluid overload and
hyponatraemia manifests as hypotension, bradycardia, confusion, nausea and, in
severe cases, convulsions.
Treatment involves infusion of 2 M saline solution combined with frusemide.
The cardinal symptoms of benign prostatic hypertrophy are poor flow, feeling of
incomplete emptying and hesitancy. Other symptoms may be as described in this
question (frequency, nocturia and terminal dribbling). These patients can develop
urinary retention and present to A&E requiring catheterization. They are started
on an alpha-receptor antagonist which relaxes the bladder neck and a trial
without catheter can be attempted. Long-term urinary retention can lead to
chronic renal failure, which manifests as uraemic symptoms and an elevated serum
creatinine level. This patient has had a transrectal ultrasound scan and biopsy to
confirm it is benign enlargement. There are no contraindications to surgery so he
can undergo transurethral resection of prostate. If he did have cancer then he
could be offered radical prostatectomy.
A 66-year-old man has recently had a routine blood screen and is reported to
have an elevated PSA of 5.5 ng/mL. He is otherwise asymptomatic.
An elevated PSA can occur for multiple reasons such as urinary tract infection,
trauma and catheterization. An incidental finding of an elevated PSA must therefore be repeated to check the result. If it remains elevated, despite being asymptomatic, the patient will require a transrectal ultrasound scan and multiple biopsies
of the prostate.
He should not have been offered a PSA test if he was asymptomatic as there is
no evidence to show that a national screening programme will bring more
benefit than harm. With a positive biopsy result he would be offered a radical
prostatectomy. In patients of advanced age or those who have significant
life-limiting comorbidities and a life expectancy of less than 10 years, active
surveillance/watch and wait protocol can be applied. Watchful waiting is a
Impaired urethral support from pelvic floor muscle weakness causes stress
incontinence. Urine leakage is associated with increased abdominal pressure from
laughing, sneezing, coughing, climbing stairs or other physical exertion.
First-line treatment for stress incontinence is pelvic floor exercises as
recommended by NICE guidelines. Drug therapies are more useful in cases of urge
incontinence. This is involuntary urine loss accompanied by a sudden strong desire to
pass urine that is difficult to suppress, a result of uninhibited bladder contraction
from detrusor hyperactivity caused by abnormalities of the CNS inhibitory pathway
such as strokes and cervical stenosis, or from infection, stones or neoplasms.
Medications in the form of anticholinergic agents inhibit the binding of acetylcholine
to the cholinergic receptor. This suppresses involuntary bladder contraction, increases
the volume of the first involuntary bladder contraction, decreases the amplitude of
the involuntary bladder contraction, and may increase bladder capacity.
Oxybutynin inhibits the action of acetylcholine on smooth muscle and has a direct
antispasmodic effect on smooth muscle, thus increasing bladder capacity and
decreasing uninhibited contractions.
A 25-year-old man presents with slowing of his urinary flow and terminal urethral
dribbling. He has a past history of a treated sexually transmitted disease.
This patient is young so his bladder outlet symptoms, given his medical history,
are likely to be due to a urethral stricture. The investigation of choice here is an
urethrogram to diagnose and display the anatomy of the stricture.
A 75-year-old woman presents with recent onset of severe urinary urgency and
bladder pain. Dipstix shows no nitrates, protein 1 and blood 2.
B
This patient is at risk of bladder cancer as the haematuria cannot be due to a urinary tract infection. Haematuria clinics are set up to assess the urinary tract by
performing urine cytology, renal ultrasound, IVU or CT, and flexible cystoscopy. If
all results are negative the patient can be reassured.
An 80-year-old man presents to the urology clinic with poor flow, frequency
and nocturia. He is noted to have an elevated creatinine.
D This man is describing symptoms of bladder outflow obstruction most likely due to an
enlarged prostate. The degree of incomplete emptying can be assessed by ultrasound.
The resultant back pressure on his kidneys is probably responsible for the elevated
creatinine. Ultrasound of the kidneys is required to assess the degree of obstruction.
A 40-year-old woman who has had two previous colposuspensions for urinary
incontinence now complains of mixed urge and stress leakage.
E
developing recurrent stones within the subsequent 10 years. The history is classic:
99 per cent of stones will be associated with at least microscopic haematuria, and
family history is relevant. This patient is likely to have had an expedited or elective
percutaneous nephrolithotomy. Patients are consented for stone recurrence, bleeding and failure to pass stone fragments. In this case the bleeding did not respond
to nephrostomy tamponade (passage of nephrostomy tube to apply local pressure
to stop bleeding); hence the next option, selective renal embolization, is
attempted. This is a radiologically guided procedure to identify the bleeding vessel.
If this fails, one would resort to open surgery to stop the bleeding.
A 35-year-old woman, in the first trimester of pregnancy, presents with severe
right loin pain.
I
Imaging is crucial, but an x-ray cannot be taken during the first trimester and
so ultrasound scanning will be necessary to identify an obstructing calculus. This
procedure is operator dependent and the results need interpreting by an
experienced ultrasonographer. Note that the right ureter is often physiologically
dilated in pregnancy.
A 50-year-old woman with diabetes presents with severe left loin pain, pyrexia,
tachycardia and a white cell count of 24 000. Intravenous urogram shows no
function on the initial 10-minute film.
A staghorn calculus is so-called for its shape which takes the form of the renal
pelvis and pyramids resembling the horn of a stag. It is composed of a triple
A Undescended testes are investigated early and, if identified and viable, are brought
down to the scrotum either by laparoscopy or open surgery. This is known as
cryptorchidism and is a risk factor for testicular cancer. The main reason for surgery is in order to allow regular examination of the affected testicle. In this case
the childs previous laparoscopy was unsuccessful, most likely due to the fact that
the testicle was maldescended (located in a position along its normal developmental track but not in the scrotum). Note that if it is located outside the normal
developmental track, this is called an ectopic testis. By this age a maldescended
testis will not contribute to fertility, which is normally adequate in the presence of
a normal contralateral testis.
An 80-year-old man has been attending his GP for 3 years with an enlarging
right-sided scrotal mass which disappears on lying flat but worsens during the
day. The GP cannot get above the mass, nor does it transilluminate.
E
The mass described is most likely to be an inguinal hernia, although it could also
be a varicocoele. A varicocoele is said to feel like a bag of worms, a hernia has a
cough impulse. Examination of a hernia can sometimes reveal whether it is an
indirect or direct inguinal hernia. Direct hernias push directly through the posterior wall of the inguinal canal and thus pressure over the internal ring after reduction will not stop it popping back through the wall. They often reduce easily and
rarely strangulate.
Indirect inguinal hernias pass through the internal inguinal ring and therefore
can be controlled by pressure over the internal inguinal ring after the hernia
has been reduced. Generally speaking, direct inguinal hernias are not felt in the
scrotum.
Femoral hernias are palpable below and lateral to the pubic tubercle, whereas
inguinal hernias can be felt above and medial to this landmark. Femoral hernias
are often irreducible and likely to strangulate.
A 69-year-old woman with right leg pain is diagnosed with a deep vein
thrombosis on Doppler investigation. On examination there are firm rubbery
matted masses in both groins.
Although direct pressure of a femoral aneurysm on the femoral vein can lead to
venous obstruction and thrombosis, in this case the most likely answer is inguinal
lymphadenopathy by the same pressure effect. The cause of the inguinal
lymphadenopathy should be investigated.
53 Urological imaging/intervention
Answers: 1J, 2K, 3I, 4E, 5D
A 45-year-old man has muscle-invasive transitional cell carcinoma of the bladder extending to multiple sites along the right ureter and involving the renal
pelvis.
J
Filling defects can be seen on IVU, but in this case the diagnosis of muscle-invasive
bladder disease is given indicating that retrograde urography has been performed.
Cystoscopy is essential as 50 per cent of patients with upper urinary tract tumours
have associated tumours in the bladder. Retrograde urography involves cannulation
of the ureteric orifice at the time of cystoscopy and injection of contrast medium
followed by x-ray imaging to look for a filling defect in the affected segment of
ureter. Further management involves staging CT to look for the presence of distant
metastases. Muscle-invasive disease involving the kidney, ureter and bladder
requires radical treatment.
Management of his prostate cancer involves watchful waiting which is also known
as active surveillance. This is disease monitoring with clinical examination and PSA
testing and treatment of symptoms as and when they arise. HIFU is high-intensity
focused ultrasound which is a minimally invasive form of treatment for prostate
cancer but still requires a general anaesthetic and can cause some postoperative
symptoms.
A 45-year-old man has raised PSA of 29 ng/mL and positive TRUS biopsy
results. His brother died of prostate cancer aged 60 years.
This man has a positive family history. He needs full staging, followed by a radical
prostatectomy, followed by radiotherapy as appropriate.
A 30-year-old man with a history of renal stones has been on a business trip
and taken diclofenac and codeine throughout his meetings. He returns to
attend A&E with further pain.
The investigation of choice here is ultrasound of the urinary tract. This man may
well have an obstructed system and would need an urgent drainage, either in the
form of a JJ stent or a nephrostomy to promote drainage. An ultrasound will show
an obstructed system without the use of contrast and the degree of obstruction
will indicate whether nephrostomy or JJ stent is more appropriate. It is important
to appreciate urosepsis as he is young and tolerates the stress response better. His
creatinine will be grossly deranged and, although he may be pain-free, he is likely
to have loin tenderness.
A 15-year-old female complains of severe loin pain when voiding.
D The working diagnosis is vesicoureteric reflux. The incompetent valve-like mechanism at the vesicoureteric junction allows increases in bladder pressure to be
reflected to the kidneys, causing pain. This pain is apparent only during voiding
and can be demonstrated on performing a micturating cystourethrogram.
Treatment involves reimplantation of the ureters or subtrigonal injection of
Polytef, collagen or Macroplastique into the ureteric orifices.
54 Renal masses/tumours
Answers: 1C, 2K, 3H, 4F
A 57-year-old man with acute cholecystitis undergoes ultrasound scanning of
the abdomen. An incidental note of a renal lesion is made. The patient is
informed and reassured that it is benign.
C
Simple cysts are the most common cystic renal lesion. They are usually asymptomatic and approximately one-third to one-half of people older than 50 years have
one or more renal cysts. They are most commonly detected by ultrasound.
If there is any evidence of calcifications, septa or multiple cysts which may
obscure a carcinoma, renal CT scanning with contrast medium should be performed. Other cystic lesions can be Bosniak cysts, medullary sponge kidney
(strongly associated with nephrolithiasis), acquired renal cystic disease seen in
patients with end-stage renal failure, adult polycystic kidney disease, and renal
cysts of Von HippelLindau syndrome (VHL is a tumour suppressor gene). Simple
cysts are the only benign ones.
A 46-year-old woman presents with a 3-month history of haematuria, weight
loss, fevers, lethargy and loin pain, and a palpable loin mass. She has no significant past medical history, or travel history.
Renal cell carcinoma presents as the classic triad of haematuria, loin pain and a
palpable mass in only about 10 per cent of cases. Some present with clot colic
mimicking ureteric colic, but they can also present with paraneoplastic syndromes
or non-specifically as pyrexia of unknown origin. Hypercalcaemia occurs due
to ectopic PTH-like hormone production and polycythaemia due to excess
erythropoietin production.
A 23-year-old man attends A&E having fallen off a motorbike at 30 miles per
hour. He presents with an expanding left loin mass, bruising and haematuria.
Vertigo
Sore throat
Nasal blockage
Hoarse voice
Dysphagia
Ear pain
Acute paediatric airway obstruction
Swelling in the neck
QUESTIONS
55 Vertigo
A
B
C
D
E
Menires disease
vertebrobasilar insufficiency
hypercalcaemia
acute labyrinthitis
benign paroxysmal positional
vertigo (BPPV)
F
G
H
I
acoustic neuroma
temporal arteritis
cholesteatoma
osteoarthritis of neck
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 45-year-old man has a 4-month history of attacks of vertigo which lasts for
hours associated with tinnitus and reduced hearing in the left ear. There is associated nausea.
A 38-year-old woman presents with severe vertigo and vomiting which lasts for
days. There is no loss of hearing or tinnitus.
A 30-year-old woman presents with a history of chronic ear infections. She complains of an offensive discharge from her right ear with associated hearing loss for
months. She has had severe vertigo for the last 48 hours.
56 Sore throat
A
B
C
D
glandular fever
quinsy
chronic tonsillitis
acute tonsillitis
E
F
G
H
gastro-oesophageal reflux
foreign body in throat
lymphoma
squamous cell carcinoma of tonsil
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 20-year-old man presents with a 3-day history of a worsening sore throat and
raised temperature. He is complaining of right otalgia, difficulty opening his
mouth and a change in his speech. On examination he has trismus (difficulty
opening mouth), tonsil inflammation and soft palate swelling on the right side.
The uvula is deviated to the left.
A 50-year-old man presents with a daily sore throat, worse in the morning, with
no general malaise, temperature, dysphonia or dysphagia. This has persisted for
2 months despite multiple courses of antibiotics.
A 70-year-old man presents with a 5-week history of right-sided sore throat and
worsening pain on swallowing. He has associated otalgia. He smokes 20 cigarettes
every day and is known to be a heavy drinker.
57 Nasal blockage
A
B
C
D
foreign bodies
perennial allergic rhinitis
rhinitis medicamentosa
deviated nasal septum
E
F
G
H
nasal polyps
deviated nasal bones
Wegeners granulomatosis
nasopharyngeal carcinoma
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 40-year-old man presents with a history of bilateral nasal blockage. He has temporary relief with an over-the-counter decongestant that he has been using for
the last 2 months.
58 Hoarse voice
A
B
C
D
E
F
G
H
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 45-year-old woman presents with a hoarse voice. She has taken numerous overdoses requiring admission to ITU and intubation.
A 48-year-old man presents with a 2-month history of hoarse voice. He takes oral
antacid therapy for indigestion and denies any dysphagia.
59 Dysphagia
A
B
C
D
E
foreign body
pharyngeal pouch
oesphageal varices
hypopharyngeal carcinoma
MalloryWeiss syndrome
F
G
H
I
J
globus pharyngeus
thyroid goitre
motor neuron disease
oesophageal atresia
diffuse oesophageal spasm
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 75-year-old man wakes up in the middle of the night with sudden onset of
pain in the neck and difficulty swallowing his saliva. He has no symptoms during
the day.
60 Ear pain
A
B
C
D
E
temporomandibular joint
dysfunction
G malignant otitis externa
H trigeminal neuralgia
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 5-year-old boy with an upper respiratory tract infection had a 24-hour history
of severe pain in his right ear followed by a pus-like discharge with resolution of
pain.
A 72-year-old woman presents with severe left-sided ear pain followed by weakness to her face including eye closure. Vesicles are evident on her pinna.
A 40-year-old man has a 2-month history of intermittent right earache. There are
no other ear symptoms. The pain is localized to the pre-auricular region. He is
known to grind his teeth (bruxism) at night.
laryngeal papillomatosis
foreign body
chronic obstructive airways disease
acute laryngotracheobronchitis
(croup)
E
F
G
H
I
laryngomalacia
Down syndrome
acute epiglottitis
childhood asthma
acute tonsillitis
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 5-year-old girl with a 2-month history of a hoarse voice presents with worsening stridor over the last 72 hours. There is no associated temperature. This has
been her third admission in just over a year with a similar problem.
A 4-year-old girl presents with a 24-hour history of general malaise and has
developed a barking, noisy cough with difficulty in breathing. There is no drooling.
branchial cyst
thyroid nodule
cervical rib
lymphoma
chemodectoma
F
G
H
I
J
sternomastoid tumour
dermoid cyst
pharyngeal pouch
thyroglossal cyst
cystic hygroma
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 3-year-old boy is seen by his GP with a enlarging midline swelling that has been
present for the past year. It is smooth and rounded, located just below the hyoid
bone, measuring 2 cm 2 cm, and rises on protrusion of the tongue.
A 32-year-old woman presents to her GP with a neck lump enlarging for the last
3 years. It measures 1 cm 1.5 cm and is located behind the junction of the upper
and middle thirds of the left sternocleidomastoid muscle. In the past this lump has
become infected, resolving with oral antibiotics.
ANSWERS
55 Vertigo
Answers: 1E, 2A, 3D, 4F, 5H
A 50-year-old woman wakes in the middle of the night complaining of a spinning sensation with nausea that lasts for about 30 seconds. The symptoms are
most obvious turning over onto the right side.
E
This woman has BPPV. The pathophysiology is under much debate, but detachment
of calcium carbonate crystals (otoliths) that become detached from the utricle and
saccule is perceived to be the likely pathology. The otoliths migrate to the posterior semicircular canal and stimulate the vestibular nerve on specific head movements. This causes a rotatory nystagmus. The diagnosis is confirmed with a positive
Hallpike Dix manoeuvre.
The patient is asked to sit upright with head facing the examiner. The examiner
grasps the patients head between his hands and rapidly moves the patient from a
sitting to lying position with the head tipped below the horizontal plane, 45 to
the side, and with the side of the affected ear (and semicircular canal) downwards.
A positive test provokes vertigo and rotatory nystagmus that typically has a
latency of a few seconds before onset and fatigues after about 30 seconds. If the
nystagmus appears immediately on performing the manoeuvre and does not
fatigue, a cerebellar mass lesion may be responsible and CT should be performed.
Treatment of BPPV is by an Epley repositioning procedure. A Hallpike manoeuvre is
performed initially followed by stepwise rotations of the head to the opposite side
before sitting the patient up. It is thought that this manoeuvre provides relief by
dislodging otoliths from the posterior semicircular canal.
A 45-year-old man has a 4-month history of attacks of vertigo which lasts for
hours associated with tinnitus and reduced hearing in the left ear. There is
associated nausea.
the other ear. Surgery is indicated only in carefully selected severe cases and
includes grommet insertion with administration of drugs (e.g. gentamicin) to
ablate vestibular function, and endolymphatic surgery (though there are mixed
results on the benefit of this).
A 38-year-old woman presents with severe vertigo and vomiting which lasts
for days. There is no loss of hearing or tinnitus.
D Acute labyrinthitis usually has a viral infective origin and is often preceded
by an upper respiratory tract infection. There is a sudden onset of rotatory
vertigo, nausea and vomiting. Symptom severity can result in the patient being
confined to bed for days. Treatment involves the use of vestibular sedatives (e.g.
prochlorperazine). Hospital admission is sometimes necessary for cases of
intractable vomiting.
A 75-year-old man reports a chronic history of left-sided tinnitus and gradual
hearing loss. He has recently been complaining of headaches and a sensation
of unsteadiness when walking.
F
Acoustic neuroma is a rare, benign, slow-growing tumour of the VIII cranial nerve
which rarely presents with vertigo. It more often presents with unilateral tinnitus
and deafness (rarely sudden-onset). Large tumours may cause facial pain, numbness and paraesthesia through trigeminal nerve stimulation. Any asymmetrical
cochlear symptoms require investigation for this condition with an MRI scan. If
the acoustic neuroma is small a watch and wait policy can be adopted with serial
MRI scans. Treatment options include surgery or radiotherapy.
A 30-year-old woman presents with a history of chronic ear infections. She
complains of an offensive discharge from her right ear with associated hearing
loss for months. She has had severe vertigo for the last 48 hours.
56 Sore throat
Answers: 1B, 2A, 3D, 4E, 5H
A 20-year-old man presents with a 3-day history of a worsening sore throat
and raised temperature. He is complaining of right otalgia, difficulty opening
his mouth and a change in his speech. On examination he has trismus (difficulty opening mouth), tonsil inflammation and soft palate swelling on the right
side. The uvula is deviated to the left.
B
This man has a right-sided quinsy. This is due to a collection of pus around the
fibrous capsule of the tonsil causing the soft palate to bulge. Aspiration of this pus
under topical anaesthesia is usually performed as it can dramatically improve the
significant symptoms. Antibiotic therapy is commenced depending on local protocols (usually a cephalosporin plus anaerobic cover with metronidazole). Trismus
occurs due to inflammation involving the pterygoid muscles which open and close
the mouth. Patients with recurrent quinsy should be considered for tonsillectomy.
An 18-year-old woman presents with a 7-day history of general malaise and
increasing throat pain, causing her difficulty in eating and drinking. On examination the tonsils are enlarged and inflamed with a sloughy exudate on the
surface. There is marked cervical lymphadenopathy. Full blood count shows a
lymphocytosis. Paul Bunnell test is positive.
H Squamous cell carcinoma of the tonsil presents in adults with persistent unilateral
throat pain and painful swallowing (odynophagia) often with referred otalgia to
the same side. Risk factors include smoking and excessive alcohol consumption.
Metastases can occur to nodes in the neck. The tonsil is enlarged and often ulcerated on the affected side. There may be palpable neck nodes.
Treatment is dependent on the stage of the tumour and may include surgery combined with radiotherapy. Large tumours may require some reconstruction of the
pharyngeal defect with a free flap (e.g. radial forearm).
57 Nasal blockage
Answers: 1E, 2A, 3B, 4C, 5D
A 40-year-old known asthmatic presents with gradual blockage of both nostrils. The GP examined the nose and noted pale swellings in both nasal cavities.
The patient is known to be sensitive to aspirin.
E
Nasal polyps are non-neoplastic swellings arising from the lining of the sinus
mucosa. Their aetiology is currently unknown, although studies have postulated
allergic, genetic or infective (particularly fungal) causes. At present there is no
definitive curative therapy.
Rhinitis medicamentosa is where the lining of the nose (inferior turbinates) swells
up and causes nasal obstruction through the prolonged use of nasal
vasoconstrictors (e.g. xylometazoline drops). It is thought to occur due to a
rebound vasodilatation of the blood vessels within the lining of the nose. It is
recommended that people should not take topical nasal decongestants for more
than 1 week.
58 Hoarse voice
Answers: 1B, 2A, 3D, 4E, 5G
A 30-year-old lead singer of a rock band presents with a 2-month history of a
hoarse voice. This is painless and there is no dysphagia.
B
Vocal cord nodules arise from vocal misuse and are otherwise known as singers
or screamers nodules. They are painless, normally bilateral and affect the anterior
part of the larynx. This is the most common cause of a hoarse voice in children.
Treatment is conservative with speech and language therapy.
A 45-year-old woman presents with a hoarse voice. She has taken numerous
overdoses requiring admission to ITU and intubation.
A Vocal cord granulomas are non-neoplastic swellings affecting the posterior part of
the laryngeal framework (arytenoid cartilages) and can be unilateral or bilateral.
They occur as a result of chronic trauma particularly with contact through prolonged intubation on ITU. Treatment is conservative through voice therapy, though
the patient may need to have a diagnostic microlaryngoscopy and biopsy under a
general anaesthetic.
A 75-year-old man presents with a 2-month history of a hoarse voice. He is a
smoker of 20 cigarettes per day.
D Squamous cell carincoma of the larynx is the commonest head and neck cancer
in the western world. Its incidence increases with age, presenting most commonly in
the seventh decade, with males affected more than females. Smokers and alcohol
drinkers are at increased risk of developing this disease.
Any unexplained persistent hoarseness lasting more than 6 weeks requires urgent
referral to an ENT specialist. Squamous cell carcinomas of the vocal cords normally
present early because small tumours cause hoarseness. As they increase in size
they can cause difficulty in breathing (particularly symptoms of stridor) and
dysphagia through involvement of the pharynx and spread to lymph nodes in the
neck. Treatment is dependent on the size of the tumour and includes radiotherapy
for small lesions and surgery (e.g. laryngectomy) for larger tumours.
The recurrent laryngeal nerve is the main motor supply for the muscles of the larynx. The left nerve descends into the chest before returning into the neck to enter
the larynx. In this way a patient with a left-sided vocal cord palsy may have chest
pathology (e.g. lung malignancy) as a potential cause. Other causes include other
malignancies (e.g. oesophagus, thyroid), iatrogenic from thyroid surgery, and penetrating trauma.
Unilateral palsy may present with hoarseness and a weak cough (bovine). This
may be treated with speech and language therapy to strengthen the mobile side,
or with surgery to allow the opposite side of the larynx to meet the paralysed
side (teflon injection of paralysed cord, medialization of the paralysed cord e.g.
thyroplasty). If there is a bilateral cord palsy the patient may present with stridor
and an emergency tracheostomy may be warranted in order to stabilize the
airway.
A 48-year-old man presents with a 2-month history of hoarse voice. He takes
oral antacid therapy for indigestion and denies any dysphagia.
59 Dysphagia
Answers: 1B, 2D, 3F, 4G, 5A
A 70-year-old man presents with dysphagia and regurgitation of undigested
food after about 5 minutes.
B
G An enlarged thyroid gland (goitre) can cause dysphagia by pressure effects on the
oesophagus which lies posterior to the trachea. This can occur particularly in cases
of retrosternal extension. These are indications for surgery. A rapidly enlarging
gland with dysphonia raises the possibility of an anaplastic cancer or lymphoma.
A 75-year-old man wakes up in the middle of the night with sudden onset of
pain in the neck and difficulty swallowing his saliva. He has no symptoms during the day.
A The most likely cause is a swallowed denture plate. With a large plate the patient
may have difficulty swallowing saliva. Pain is a main feature.
A lateral soft tissue neck x-ray may show part of the plate if radio-opaque. Other
findings such as increased prevertebral shadowing of air in the oesophagus may
also be seen on the plain x-ray. A barium swallow would show a filling defect.
60 Ear pain
Answers: 1D, 2A, 3C, 4F, 5G
A 30-year-old man presents with a 2-day history of severe right-sided earache
after a recent holiday abroad. On examination there is marked tragal tenderness. The ear canal is swollen and filled with debris.
D Otitis externa is inflammation within the external auditory meatus. Risk factors
include cotton bud usage, water exposure, eczema and diabetes. The most common organism is Pseudomonas aeruginosa. Treatment includes topical antibiotic
and steroid ear drops and aural toilet. In cases of marked oedema of the ear canal,
insertion of a sponge wick allows the antibiotic drops to penetrate to the deeper
part of the canal. Chronic ear drop use should be discouraged as it may lead to
fungal infection (e.g. Aspergillus niger) with visible spores and hyphae.
A 5-year-old boy with an upper respiratory tract infection had a 24-hour
history of severe pain in his right ear followed by a pus-like discharge with
resolution of pain.
A Acute otitis media is infection within the middle ear space. It is more common in
children and may present with otalgia and general malaise following an upper respiratory tract infection. The tympanic membrane can rupture due to a build-up of
pus in the middle ear alleviating the pain but resulting in a purulent discharge.
In very small children the symptoms may be more non-specific with poor feeding,
irritability and pyrexia.
The most common organisms include Streptococcus pneumoniae and
Haemophilus influenzae. Treatment includes antibiotics, analgesics and antipyretics. Complications can arise albeit rarely and include mastoiditis, meningitis and
intracranial abscesses.
A 72-year-old woman presents with severe left-sided ear pain followed by
weakness to her face including eye closure. Vesicles are evident on her pinna.
C
Herpes zoster oticus (Ramsey Hunt syndrome) is a viral infection which causes
vesicles on the pinna or external auditory meatus, lower motor neuron VII nerve
palsy and marked otalgia. This is more common in the elderly. Treatment includes
steroids, aciclovir and eye care (regular drops, ointment and an eye patch at night
if unable to close the eyelids fully to prevent corneal abrasion).
A 40-year-old man has a 2-month history of intermittent right earache. There
are no other ear symptoms. The pain is localized to the pre-auricular region. He
is known to grind his teeth (bruxism) at night.
F
Temporomandibular joint dysfunction can present with referred otalgia. There may be
a history of trauma to the joint (strained during yawning or chewing) or teeth grinding (bruxism). There is often associated muscular spasm. Treatment options include
drugs (NSAIDs, benzodiazepines), dental splints, steroid injections and joint surgery.
A 71-year-old diabetic patient presents with a 4-week history of severe
left-sided earache. The pain radiates down his jaw and keeps him awake at night.
The presentation of a foreign body in the airway is dependent on its size and
whether the foreign body is organic or corrosive (e.g. a hearing aid battery). A
small non-organic foreign body may present with a brief episode of choking,
cyanosis and little else. There may be occlusion of a bronchus with subsequent
collapse of a lobe causing shortness of breath. A large foreign body may result in
occlusion of the airway at the level of the larynx with laryngospasm resulting in
death. Organic foreign bodies (e.g. peanut) can cause marked inflammation in the
lower airways due to the oil irritating the mucosa. Removal via a bronchoscope
can be quite challenging as the peanut tends to fragment into small pieces.
A 4-year-old girl presents with a 24-hour history of general malaise and has
developed a barking, noisy cough with difficulty in breathing. There is no
drooling.
Laryngomalacia can present soon after birth. It is the most common cause of stridor in infants. There is infolding of the epiglottis (floppy epiglottis) into the airway
on inspiration. This is normally a self-limiting condition, but if the stridor becomes
severe with signs of respiratory distress (in-drawing of intercostals and use of
accessory muscles) and affected feeding, surgery is recommended to improve the
airway.
A chemodectoma is a benign tumour arising from neural crest cells of the carotid
body at the junction of the bifurcation of the carotid. A pulsatile mass is present
which moves in a lateral but not vertical direction and has a bruit on auscultation.
Angiography shows widening of the carotid bifurcation (known as the lyre sign).
Ten per cent of tumours are malignant, 10 per cent familial and 10 per cent
secrete catecholamines. Surgery is the main treatment, though radiotherapy is
indicated in patients not suitable for surgery.
A 23-year-old girl complains of intermittent numbness and paraesthesia in her
right hand for the past 2 months. On examination there is a fixed, hard,
1 cm 2 cm swelling in the right supraclavicular fossa.
A cervical rib is a supernumery rib which arises from the costal part of the seventh
cervical vertebra. It occurs above the first rib and may press on neurovascular
structures including the brachial plexus and subclavian artery. It can present as a
hard mass in the posterior triangle with concomitant upper limb symptoms
including paraesthesia, pain and weakness.
A 3-year-old boy is seen by his GP with a enlarging midline swelling that has
been present for the past year. It is smooth and rounded, located just below the
hyoid bone, measuring 2 cm 2 cm, and rises on protrusion of the tongue.
A A branchial cyst is a neck swelling which is thought to arise from either the
embryological remnants of first and third pharyngeal pouches, or from cystic
degeneration within a lymph node. The cyst presents in young adults at the
SECTION 6: EMQS IN
OPHTHALMOLOGY
63
64
65
66
67
68
69
70
71
72
Red eye
Diseases causing cataracts
Neuro-ophthalmology: pupils
Neuro-ophthalmology: visual fields
Ocular pharmacology
Ocular motility and ptosis
Ocular and orbital pathology
Retinal pathology
Optic nerve pathology
Inherited eye disease
EMQs in ophthalmology
QUESTIONS
63 Red eye
A
B
C
D
E
F
G
scleritis
acute anterior uveitis
episcleritis
subtarsal foreign body
atopic conjunctivitis
posterior uveitis
conjunctival haemorrhage
H
I
J
K
L
M
endophthalmitis
cicatricial pemphigoid
StevensJohnson syndrome
chronic blepharitis
acute angle closure glaucoma
rosacea keratitis
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 72-year-old man had cataract surgery about a week ago and developed a
painful, red, congested eye, discharge, hypopyon and reduced red reflex. There was
no fundus view.
A 25-year-old man presents with cold sores, oral ulcers, sore throat, myalgia, bilateral eyelid swelling and conjunctivitis with pseudomembranes.
An 8-year-old boy with eczema presents with photophobia, itching, stringy discharge, crusting of the eyelids, corneal ulcer and conjunctivitis.
homocystinuria
Marfan syndrome
Turner syndrome
Down syndrome
syphilis
type I diabetes mellitus
galactosaemia
H
I
J
K
L
M
Wilsons disease
Alport syndrome
myotonic dystrophy
type II diabetes mellitus
pemphigus
Lowes syndrome
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A child aged 5 years presents to the eye clinic with learning difficulties, bilateral
cataracts, epicanthic folds, myopia, Brushfield spots and blue-dot cataracts.
A 3-year-old child presents with learning difficulties and failure to thrive. She is
found to have non-glucose reducing substance in the urine.
65 Neuro-ophthalmology: pupils
A
B
C
D
E
F
G
tonic (Adie)
Marcus Gunn
III nerve palsy
Argyll Robertson
preganglionic Horners syndrome
postganglionic Horners syndrome
central Horners syndrome
H
I
J
K
L
M
traumatic mydriasis
Parinaud syndrome
physiological anisocoria
senile miosis
aberrant III nerve regeneration
pontine haemorrhage
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 50-year-old smoker presents with left-sided miosis, ptosis and anhydrosis. Chest
x-ray shows an apical opacity in the left upper lobe. After testing with cocaine
4 per cent and adrenaline 1:1000, the left pupil remains undilated.
A 45-year-old woman presents with sudden-onset blurred vision in the right eye
of 6/12 with fixed dilated pupil, right-sided ptosis, and down and out looking
right eye. She is hypertensive at 200/115 mmHg.
homonymous hemianopia
superior quadrantanopia
inferior quadrantanopia
central scotoma
tunnel vision
junctional scotoma
altitudinal field defect
H
I
J
K
L
M
bitemporal hemianopia
arcuate scotoma
centrocaecal scotoma
wedge scotoma
nasal step
Seidel scotoma
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 52-year-old man with night blindness presents to the eye clinic. Fundus examination shows spicule pigmentation, pale optic discs and arteriolar narrowing.
Visual field testing shows bilateral symmetrical constricted fields.
A 34-year-old woman presents with decreased vision in the right eye to 6/18. She
also complains of photophobia and pain on ocular movements. On examination
she has a relative afferent pupillary defect, impaired colour vision and disc
swelling. She has been diagnosed with multiple sclerosis a year previously. Visual
field testing shows absent central field in the right eye.
67 Ocular pharmacology
A
B
C
D
E
F
G
H
I
J
K
L
M
For each scenario below, suggest the most appropriate drug. Each option may be
used only once.
1
A 32-year-old man was poked in the right eye by a branch. A few hours later he
presents to A&E with a painful, photophobic left eye and reduced visual acuity of
6/60. A casualty officer applies a topical drop to diagnose a corneal abrasion.
A 50-year-old man receives first-line topical therapy for reversing an acute angle
closure glaucoma attack.
A 42-year-old woman presenting with severe pain and loss of vision secondary to
an acute angle closure glaucoma attack requires intravenous therapy to reduce
raised intraocular pressure of 60 mmHg.
H
I
J
K
L
M
mechanical ptosis
levator dehiscence
myotonic dystrophy
aberrant III nerve regeneration
plexiform neurofibroma
blepharochalasis syndrome
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 70-year-old woman presents with bilateral symmetrical ptosis, with good levator
function and high upper eyelid crease.
H
I
J
K
L
M
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
An 8-year-old febrile child presents with swelling, ptosis and redness of the right
eyelids. There is warmth of the overlying skin.
A 75-year-old man presents with a nodular blue-black lesion on the left upper
eyelid. Two years ago he had an excised black pigmented conjunctival lesion found
to be malignant. On this examination there is thickening of the eyelid margin and
loss of eyelashes. Lid biopsy histology shows atypical melanocytes throughout the
skin epidermis.
A 36-year-old man presents with a painful proptosed left eye. He was involved in
a road traffic accident a month previously. Since then he has complained of flushing noises in his head. On examination he has dilated conjunctival and episcleral
vessels, raised intraocular pressure of 38 mmHg and left VI nerve palsy. He was
referred to the neurosurgeons for further management.
70 Retinal pathology
A
B
C
D
E
F
G
H
I
J
K
L
M
retinopathy of prematurity
sickle-cell retinopathy
diabetic maculopathy
Coats disease
Bests vitelliform dystrophy
retinal artery macroaneurysm
For each clinical scenario below, suggest the most appropriate retinal pathology.
Each option may be used only once.
1
A 58-year-old smoker presents with sudden painless loss of vision in the right eye.
On examination there is a relative afferent pupillary defect, and fundoscopy shows
tortuous venous dilatation, flame and dot haemorrhages, and cotton wool spots.
A 42-year old smoker presents with blurred vision in the right eye. On fundus
examination there is arteriolar narrowing with flame-shaped haemorrhages, optic
disc swelling, cotton wool spots and a macular star.
A 34-year-old myope presents with reduced vision in the left eye, with a 2-day
history of floaters, flashing lights and shadow across the vision.
H
I
J
K
L
M
Bergmeister papillae
opticociliary shunts
optic atrophy
tilted disc
optic disc hypoplasia
optic disc cupping
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 7-year-old is sent by the paediatric team for ophthalmic review. They are concerned about bilateral disc swelling on direct ophthalmoscopy, and CT scan which
shows radio-opaque opacities at the optic nerves. On examination, fundoscopy
shows unclear disc margins.
A 25-year-old man diagnosed with multiple sclerosis presents with reduced visual
acuity of 6/9. He previously had an episode of painful loss of vision in the right
eye a year ago.
ankylosing spondylitis
retinoblastoma
Behet disease
type I neurofibromatosis
type II neurofibromatosis
multiple sclerosis
Marfan syndrome
H
I
J
K
L
M
aniridia
retinitis pigmentosa
choroideraemia
Lebers hereditary optic neuritis
homocystinuria
ocular albinism
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 19-year-old tall myopic man presents to the clinic with a 2-day history of flashing lights and floaters in the right eye with retinal detachment. The lens in either
eye is found to be dislocated superotemporally.
A 2-year-old child is brought to clinic following referral by the GP, who incidently
found left-sided abnormal white pupillary reflex, whereas the right eye had a normal red pupillary reflex. Fundoscopy reveals a white cottage-cheese like mass
with superficial blood vessels. CT scan shows an opacity at the left optic nerve.
A 40-year-old profoundly deaf man is referred by his GP for poor vision especially
in the dark. On examination fundoscopy shows spicule pigmentation, arteriolar
narrowing and optic disc pallor, and field tests reveal bilateral tunnel vision.
ANSWERS
63 Red eye
Answers: 1H, 2J, 3E, 4L
A 72-year-old man had cataract surgery about a week ago and developed a
painful, red, congested eye, discharge, hypopyon and reduced red reflex. There
was no fundus view.
H Endophthalmitis is a devastating infection causing a painful loss of vision after
ocular surgery. It is mainly caused by lid commensal bacteria such as
Staphlycoccus epidermidis (70 per cent). Clinical features include pain, decreased
acuity, anterior chamber activity, hypopyon, fibrin, absent red reflex and vitritis.
A 25-year-old man presents with cold sores, oral ulcers, sore throat, myalgia,
bilateral eyelid swelling and conjunctivitis with pseudomembranes.
J
Acute angle closure glaucoma is caused by the sudden closure of the angle. It
mainly occurs in people aged over 40 years, with an increased incidence in the
oriental/Asian population. Clinical features include sharp pain, decreased acuity,
coloured haloes, nausea and vomiting. Examination reveals raised intraocular pressure of 50100 mmHg, shallow anterior chamber, fixed mid-dilated pupil, ciliary
injection, corneal oedema and anterior chamber inflammation.
65 Neuro-ophthalmology: pupils
Answers: 1E, 2B, 3D, 4C
A 50-year-old smoker presents with left-sided miosis, ptosis and anhydrosis.
Chest x-ray shows an apical opacity in the left upper lobe. After testing with
cocaine 4 per cent and adrenaline 1:1000, the left pupil remains undilated.
E
Eyedrops
Preganglionic
Central
Postganglionic
Normal
Cocaine 4%
Hydroxyamphetamine 1%
Adrenaline 1:1000
, no dilatation; , dilatation
III nerve palsy pupil is dilated, fixed and in the down and out position. On examination one should urgently rule out surgical causes (posterior communicating
artery aneurysm) in a painful III nerve palsy. The main causes of a painless III nerve
palsy are hypertension and diabetes mellitus.
A 34-year-old woman presents with decreased vision in the right eye to 6/18.
She also complains of photophobia and pain on ocular movements. On examination she has a relative afferent pupillary defect, impaired colour vision and
disc swelling. She has been diagnosed with multiple sclerosis a year previously.
Visual field testing shows absent central field in the right eye.
D Central scotoma caused by papillitis is one of the clinical presentations of an optic
neuritis. One-third of patients with multiple sclerosis will present with optic neuritis
and two-thirds will have optic neuritis in the course of the disease. Optic neuritis is
essentially a demyelinating or inflammatory process affecting the optic nerve.
A 75-year-old patient who has recently suffered a stroke complains of reduced
vision to 6/24. Visual field testing shows a left hemi-field loss in both eyes.
A Homonymous hemianopia is most commonly caused by cerebrovascular accident
(stroke). Other possible causes are tumours and post-traumatic pathology. The
hemianopic pathology occurs retrochiasmally. The further posterior the lesion in
the optic tract, the more congruous (symmetrical) the hemianopia.
A 55-year-old tall acromegalic man presents with symptoms of headache,
diplopia and seesaw nystagmus. On examination there is presence of bilateral
papilloedema and retinopathy. Visual field testing shows bilateral symmetrical
outer hemi-field loss.
H Bitemporal hemianopia is associated with acromegalic patients. Acromegaly is
caused by a hypersecretion of growth hormone by a pituitary acidophil adenoma.
The hemianopia classically starts superiorly. Other ocular features of acromegaly
are angioid streaks and optic atrophy.
67 Ocular pharmacology
Answers: 1L, 2K, 3F, 4I
A 32-year-old man was poked in the right eye by a branch. A few hours later
he presents to A&E with a painful, photophobic left eye and reduced visual
acuity of 6/60. A casualty officer applies a topical drop to diagnose a corneal
abrasion.
L
Pilocarpine is a direct muscarinic agonist, and is the first-line topical therapy for
acute angle closure glaucoma. It causes decreased aqueous production and
uveoscleral outflow. In an acute angle closure glaucoma attack, pilocarpine causes
pupillary constriction which opens the angle by pulling the peripheral iris away
from the trabeculum.
A 42-year-old woman presenting with severe pain and loss of vision secondary
to an acute angle closure glaucoma attack requires intravenous therapy to
reduce raised intraocular pressure of 60 mmHg.
Horners syndrome is caused by an oculosympathetic palsy. There are three subgroups of Horners depending on the level of sympathetic chain being affected.
The subgroups are central (first-order neuron), preganglionic (second-order neuron) and postganglionic (third-order neuron). This patient has a postganglionic
Horners. Common causes for this type are cluster headaches, internal carotid
artery dissection, nasopharyngeal tumours, otitis media or cavernous sinus blockage. The pupil anisocoria (difference in pupil sizes) is worse in the dark, hence the
small constricted (myotic) pupil is more obvious in the dark.
A 75-year-old man presents with a nodular blue-black lesion on the left upper
eyelid. Two years ago he had an excised black pigmented conjunctival lesion
found to be malignant. On this examination there is thickening of the eyelid
margin and loss of eyelashes. Lid biopsy histology shows atypical melanocytes
throughout the skin epidermis.
D Ocular melanoma is the most common ocular cancer, but is still rare. It accounts
for 1 per cent of all eyelid tumours. Melanoma can start in the eyeball (95 per cent
choroidal and 5 per cent iris), eyelid and conjunctiva. The three forms of eyelid
melanoma are lentigo maligna, lentigo maligna melanoma and nodular melanoma
(most common, as in this case). Treatment involves wide local excision by frozen
section according to Breslow thickness. Adjunct therapy includes cryotherapy,
radiotherapy and immunotherapy.
A 36-year-old man presents with a painful proptosed left eye. He was involved
in a road traffic accident a month previously. Since then he has complained of
flushing noises in his head. On examination he has dilated conjunctival and
episcleral vessels, raised intraocular pressure of 38 mmHg and left VI nerve
palsy. He was referred to the neurosurgeons for further management.
K
70 Retinal pathology
Answers: 1A, 2F, 3C, 4E
A 58-year-old smoker presents with sudden painless loss of vision in the right
eye. On examination there is a relative afferent pupillary defect, and fundoscopy shows tortuous venous dilatation, flame and dot haemorrhages, and
cotton wool spots.
A Central retinal vein occlusion can be of two types, non-ischaemic or ischaemic,
and is mainly caused by hypertension and diabetes mellitus. It is one of the commonest causes of sudden unilateral blurred vision. The visual acuity ranges from
6/36 to counting fingers and there is usually presence of an afferent pupillary
defect. Clinical features include venous tortuosity, dot-blot and flame-shaped
haemorrhages, cotton wool spots and disc oedema on fundoscopy. Complications
include rubeotic glaucoma due to ischaemia of the retina. This needs to be treated
with panretinal photocoagulation.
A 42-year-old smoker presents with blurred vision in the right eye. On fundus
examination there is arteriolar narrowing with flame-shaped haemorrhages,
optic disc swelling, cotton wool spots and a macular star.
Retinal detachment (RD) is a separation of the sensory retina from the retinal
pigment epithelium (RPE) by subretinal fluid (SRF). There are two types of retinal
detachment, rhegmatogenous and non-rhegmatogenous. A rhegmatogenous RD is
due to a full-thickness defect in the sensory retina which allows SRF derived from
the vitreous into the subretinal space. The non-rhegmatogenous RD can be caused
by two mechanisms. The first involves traction between vitreoretinal membranes
pulling the sensory retina away from the RPE. The other mechanism is exudative
where the SRF derived from retinal blood supply is transmitted to the SRF through
the damaged RPE.
A 28-year-old pregnant woman in the first trimester, with type 1 diabetes mellitus, presents complaining of blurred vision. On examination there is presence
of retinal haemorrhages, cotton wool spots, exudates and new vessels on the
optic disc and retina.
Proliferative diabetic retinopathy is considered to be end-stage diabetic retinopathy. Pregnancy can rapidly increase the progression of even mild retinopathy in
a short time. This patient will have to undergo bilateral laser panretinal photocoagualation to treat this sight-threatening condition.
Papilloedema is swelling of the optic nerve head due to raised intracranial pressure. It is believed that raised intracranial CSF pressure around the optic nerve
results in transudation of fluid into the nerve with obstruction of axoplasmic
transport. It is the intra-axonal swelling of the axons with accumulation of mitochondria that causes the initial disc swelling. Treatment involves systemic
acetozolamide. In severe cases, neurosurgery is required in the form of a ventriculoperitoneal shunt.
Retinitis pigmentosa is a diffuse retinal dystrophy which affects the rod system.
There is a variety of inheritance mechanisms such as sporadic, autosomal
dominant/recessive and X-linked recessive. It commonly presents in the third
decade. Investigations (e.g. electroretinogram) show a reduced scotopic rod
response. Visual fields show tunnel vision. There are other systemic associations of
retinitis pigmentosa such as Usher syndrome, as in this case.
SECTION 7: EMQS IN
ANAESTHESIA AND
CRITICAL CARE
73
74
75
76
77
78
79
80
81
QUESTIONS
73 Arterial blood gases
Which of the blood gases in Table 73.1 best fits the following scenarios?
Table 73.1 Arterial blood gases
pH
PaO2 (kPa)
PaCO2 (kPa)
HCO3
7.0
12.2
2.2
15
7.35
10.5
4.4
23
7.0
5.5
8.0
18
7.41
12.5
4.6
26
7.35
7.8
4.5
23
7.5
14
2.9
23
7.25
9.4
8.9
22
7.55
10.5
6.0
48
7.39
11.9
5.4
25
7.4
12.4
3.9
23
A 69-year-old male patient on the cardiac ward collapses. He has no pulse and
cardiopulmonary resuscitation is initiated. ECG shows ventricular fibrillation. His
condition deteriorates as he shows asystole after 10 minutes of resuscitation. An
arterial blood gas sample is taken during resuscitation while the patient is being
ventilated with a bag and mask.
You are called to the ward at 1 a.m. to see a 79-year-old patient with breathing
difficulties. He is an ex-smoker with COPD. On oxygen at 4 L/min, pulse oximetry
shows SaO2 at 94%. Respiratory rate is 30 breaths/min. On examination his hands
feel warm and the anaesthetist notes that he has a poor cough.
74 Airway management
A oropharyngeal size 4
B laryngeal mask airway
size 4
C oral endotracheal tube cuffed
size 8
D McGill forceps
E reinforced cuffed endotracheal
tube
F nasopharyngeal airway
G laryngeal mask airway
size 2
H oral endotracheal tube uncuffed
size 3.5
I fibreoptic laryngoscope
J bougie
For each of the scenarios below select the most appropriate piece of equipment to
maintain the airway. Each option may be used only once.
1
An attempt at tracheal intubation is made on a 65-year-old man. Direct laryngoscopy reveals a view of the posterior arytenoids only and the endotracheal tube
passes into the oesophagus.
75 Anaesthetic emergencies
A
B
C
D
E
malignant hyperthermia
large pulmonary embolism
anaphylaxis
laryngospasm
regurgitation and aspiration
F
G
H
I
J
hypotension on induction
failure to intubate
bronchospasm
oesophageal intubation
incomplete reversal of paralysis
For each clinical scenario below give the most likely cause for the clinical findings. Each option may be used only once.
1
A 70-year-old woman has difficulty breathing after extubation following a general anaesthetic for an umbilical hernia repair. She had been intubated and ventilated following 100 mg of propofol, 10 mg of vecuronium and 100 g of fentanyl.
Anaesthesia was maintained with isoflurane and a further 4 mg of vecuronium
was administered 15 minutes before extubation.
76 Intravenous access
A
B
C
D
E
24G cannulae
22G cannulae
14G cannulae
intraosseous needle
three-lumen central venous line
F
G
H
I
J
For each clinical scenario suggest the most appropriate means of intravenous
access. Each option may be used only once.
1
A man is admitted to A&E after a road traffic accident. His blood pressure is
75/40 mmHg and heart rate 120 /min. He complains of marked abdominal pain.
A 45-year-old woman has been diagnosed with metastatic breast cancer and
requires repeated administration of intravenous chemotherapy. She has poor
peripheral veins.
A baby is admitted with severe diarrhoea and needs urgent resuscitation as his
consciousness level is deteriorating. The team is unable to find a vein to insert an
intravenous cannula.
The anaesthetist would like intravenous access for the induction of anaesthesia in
a fit and well adult.
77 Pain relief
A paracetamol and dihydrocodeine
B thoracic epidural analgesia
C patient-controlled analgesia with
ketorolac
D paracetamol, diclofenac and
immediate-release morphine
E fentanyl patch
F
G
H
I
J
paracetamol
morphine sulphate SR
lumbar epidural analgesia
patient-controlled analgesia with
morphine
paracetamol and diclofenac sodium
For each clinical scenario below select the most appropriate choice of pain relief.
Each option may be used only once.
1
A 65-year-old man with colon cancer requires an anterior resection. He has a significant history of chronic obstructive airways disease treated with high-dose
inhaled steroids and aminophylline. His peak expiratory flow rate is 195 mL/s. An
ITU bed has been booked for his postoperative recovery.
midazolam
atracurium
tubocurare
propofol
sevoflurane
F
G
H
I
J
suxamethonium
lorazepam
ketamine
fentanyl
cyclopropane
For each of the scenarios below select the most appropriate choice of drug. Each
option may be used only once.
1
A 16-year-old male has been admitted to the accident and emergency department
with a diagnosis of acute appendicitis. The surgical team decides to proceed to
appendicectomy immediately. After assessing the patient the anaesthetist plans to
perform a rapid sequence intubation.
79 Oxygen therapy
A nasal cannulae
B tracheal mask
C non-rebreathe mask with reservoir
bag
D endotracheal intubation
E Bain circuit
F
G
H
I
J
CPAP circuit
28 per cent fixed performance mask
nebulizer
neonatal mask
cold-water humidifier
For each clinical scenario below select the most appropriate choice of oxygen
therapy. Each option may be used only once.
1
A 20-year-old man was been knocked from his motorbike. He has a clear and
patent airway. Examination reveals a possible fractured pelvis and right femur.
A 65-year-old man with COPD was admitted to the ward with an infective exacerbation of COPD. Pulse oximetry shows 87 per cent oxygen saturation on air. He has
a letter from his chest physician which he has been told to keep with him at all
times. It describes that the patient relies on a hypoxic ventilatory drive.
80 Preoperative investigation
A
B
C
D
E
F
chest x-ray
transfer factor
peak flow rate
pulmonary function tests
CT scan
ventilationperfusion scan
G
H
I
J
K
echocardiography
ECG
body plethysmogram
MRI of chest
PET imaging
For each clinical scenario below suggest the most appropriate investigation. Each
option may be used only once.
1
A 75-year-old man with a history of smoking 1015 cigarettes a day for 35 years
is admitted for elective major surgery. He has a productive cough.
A patient is scheduled for an anterior resection. He has COPD and complains that
he has had more chest tightness recently. You wish to assess his lung function in
the pre-assessment clinic.
A 75-year-old woman attends the pre-assessment clinic prior to total hip replacement. She has had episodes of shortness of breath, chest pain and syncope.
A patient is admitted for vascular surgery to improve the blood flow to his right
leg. He is functionally severely compromised. He reports that he has started to get
chest pains when he walks for over 30 yards.
adrenaline (epinephrine)
noradrenaline (norepinephrine)
dopamine
dopexamine
vasopressin
F
G
H
I
J
For each clinical scenario below select the most appropriate choice of supportive
measure or drug for intravenous infusion or bolus. Each option may be used only
once.
1
A 58-year-old man presents with central chest pain radiating into his back. He has
a heart rate 95/min, BP 170/95 mmHg and poor urine output. ECG is normal. He is
awaiting a CT scan of his chest.
A 70-year-old diabetic Asian woman presents with intermittent central chest pain.
She is on a GTN, insulin and a heparin infusion in the cardiac unit. Coronary
angiogram shows severe triple-vessel disease. She is awaiting a coronary artery
bypass graft but presents with further chest pain in the night. Pulse 70/min,
BP 90/50 mmHg, troponin T 0.05.
A 35-year-old man with septic shock is being treated in ITU. His mean arterial
blood pressure has dropped to 65 mmHg despite adequate fluid resuscitation.
ANSWERS
73 Arterial blood gases
Answers: 1C, 2A, 3F, 4G, 5E
A 69-year-old male patient on the cardiac ward collapses. He has no pulse and
cardiopulmonary resuscitation is initiated. ECG shows ventricular fibrillation.
His condition deteriorates as he shows asystole after 10 minutes of resuscitation. An arterial blood gas sample is taken during resuscitation while the
patient is being ventilated with a bag and mask.
C
This patient has suffered a loss of cardiac output and ventilatory failure. He is
being poorly ventilated during the resuscitation. An arterial blood gas sample
would show a severe metabolic acidosis as a result of loss of cardiac output and
poor tissue perfusion. Hypoxia and hypercarbia result from poor ventilation.
Hypercarbia would worsen the acidosis. This results in combined respiratory and
metabolic acidosis.
A 20-year-old man presents semiconscious to A&E. He is known to have a family history of insulin-dependent diabetes. He takes deep breaths and his breath
smells ketotic.
This woman has a good history for a diagnosis of hyperventilation syndrome. Her
arterial blood gases would reveal a respiratory alkalosis. Carpopedal spasm is
caused by acute secondary hypocalcaemia as a result of the alkalosis.
You are called to the ward at 1 a.m. to see a 79-year-old patient with breathing difficulties. He is an ex-smoker with COPD. On oxygen at 4 L/min, pulse
oximetry shows SaO2 at 94 per cent. Respiratory rate is 30 breaths/min. On
examination his hands feel warm and the anaesthetist notes that he has a poor
cough.
G This man with COPD probably maintains an oxygen saturation within the low
90s (per cent), so a lower oxygen saturation does not necessarily imply an acute
hypoxia. It should be interpreted in the context of his baseline oxygen saturation.
In this case the patient is tachypnoeic with a poor cough. He is warm and therefore vasodilated. This would fit a picture of exacerbation of type II respiratory failure (PaO2 8 kPa and pCO2 6 kPa) leading to a respiratory acidosis. The CO2
retention is the cause of the vasodilated circulation.
A 25-year-old known asthmatic is complaining of difficulty breathing in A&E.
She has been feeling unwell for some days. She is unable to speak a full sentence and her lips look cyanosed.
E
This girl is presenting with acute type I respiratory failure secondary to asthma.
She is likely to have a normal or slightly low CO2. One should be wary of the asthmatic patient whose CO2 starts to rise as this implies that the patient is tiring and
developing a ventilatory failure. This would be a clear indication for ITU/specialist
care.
74 Airway management
Answers: 1C, 2H, 3G, 4I, 5J
Airway management during anaesthesia follows three principles:
maintaining a clear airway
protecting the airway from soiling by blood, secretions and gastric contents
providing a secure and reliable airway.
Every patient should have the airway assessed on the preoperative visit. Risk factors for a difficult airway or of aspiration should be identified and a plan formulated for how the airway will be managed.
A 20-year-old male needs an appendicectomy urgently. He is septic and unwell.
The surgeon wants to operate as soon as possible.
C
This patient needs a protected airway rapidly secured after induction of anaesthesia. He is at high risk of regurgitation and aspiration on induction. A rapid
sequence induction should be performed and the airway protected with a cuffed
endotracheal tube (ETT). Size 89 is appropriate for a male and size 78 would be
appropriate for females.
A newborn baby has difficulty breathing and needs ventilation.
H This baby needs tracheal intubation to protect the airway and to facilitate ventilation. Though laryngeal mask airways (LMA) have been used in resuscitations they
would not be appropriate for prolonged ventilation. Uncuffed tracheal tubes are
used in babies and children under the age of 7 years or body weight less than
35 kg. These reduce the incidence of post-extubation stridor and tracheal stenosis.
There should be a noticeable air leak around the tube at an airway pressure of
25 cmH2O. A newborn takes a size 3 3.5 tube, and after age 12 months tubes can
be sized using the formula: ETT internal diameter age/4 4 mm.
In a patient with an unstable cervical spine fracture an awake fibreoptic intubation is indicated. This allows the airway to be secured without undue manipulation
of the cervical spine.
An attempt at tracheal intubation is made on a 65-year-old man. Direct laryngoscopy reveals a view of the posterior arytenoids only and the endotracheal
tube passes into the oesophagus.
75 Anaesthetic emergencies
Answers: 1D, 2B, 3A, 4J
An obese 40-year-old woman undergoes examination under anaesthetic for an
anal fissure. She is induced with propofol and alfentanil. Anaesthesia is maintained with isoflurane. She is lightly anaesthetized in a head-down position
with a laryngeal mask airway in place and a clear airway. Ten minutes after the
procedure has commenced, she develops marked stridor and reduction in tidal
volumes.
D Laryngospasm can occur from direct stimulation of the vocal cords or as a
response to noxious stimulation at a different site. The airway reflexes are
increased during the excitatory phase of anaesthesia (i.e. during induction and
emergence). Any secretions, blood or instrumentation stimulating the cords may
lead to spasm. Indirect laryngospasm can occur during a painful procedure if the
depth of anaesthesia or degree of analgesia is inadequate. This patient was
induced with two short-acting agents which would have worn off by the time of
surgical stimulation and she was lightly anaesthetized with isoflurane. The management of the patient would be to increase oxygen to 100 per cent, maintain
CPAP and deepen anaesthesia.
A 40-year-old woman is undergoing emergency surgery for a comminuted tibial fracture. While the surgeon is manipulating the fracture, the anaesthetist
notices a sudden loss of end tidal carbon dioxide trace.
B
Any loss of the end tidal carbon dioxide trace should be taken seriously. Usually it
is due to equipment issues such as a blocked sampling line or disconnection.
However, if cardiac output is significantly reduced then CO2 delivery to the lungs
falls and a drop in the end tidal CO2 level will be noted. In the event of a massive
pulmonary embolism the first sign may be loss of the end tidal CO2.
A 24-year-old woman is undergoing a diagnostic laparoscopy. She has never
had a general anaesthetic before. Following intravenous induction, anaesthesia
is maintained with isoflurane. The patient develops a sudden tachycardia. A
rapid increase in the end tidal carbon dioxide trace is noted.
76 Intravenous access
Answers: 1C, 2H, 3D, 4E, 5B
A man is admitted to A&E after a road traffic accident. His blood pressure
is 75/40 mmHg and heart rate 120/min. He complains of marked abdominal
pain.
C
The diameter of the cannula determines the infusion rate as flow is directly proportional to the radius to the power of 4. Therefore, if blood has to be given where
larger particles such as erythrocytes are transfused, a larger bore cannula is preferred. In resuscitation, 14G cannulae are the intravenous access of choice, and
two 14G should be inserted (flow rate of 250 mL/min). In exceptional circumstances such as liver surgery where major blood loss is expected a Swan introducer
is used (7F).
Cannula gauges are defined by steel wire gauge. This is the number of steel
wires of the same diameter as the cannula that fit into a standard sized hole.
Therefore the higher the gauge number the smaller the cannula. Cannulae are
colour-coded:
yellow 24G suitable for neonates and babies
blue 22G
pink 20G suitable for i.v. crystalloid
green 18G smallest for volume resuscitation, blood and colloids
grey 16G
orange 14G.
A 45-year-old woman has been diagnosed with metastatic breast cancer and
requires repeated administration of intravenous chemotherapy. She has poor
peripheral veins.
H There are a number of long-term central venous cannulation systems available for
patients requiring prolonged intravenous drug administration. These are usually
tunnelled under the skin for a short distance to reduce the risk of line infection.
They should be used with full aseptic precautions. The Hickman line is a
single-lumen soft cannula which is tunnelled under the skin with the distal end
projecting out of the skin. The portacath system is a completely subcutaneous system with an injection reservoir buried beneath the skin. The permacath is a tunnelled long-term line for renal replacement therapy. A vascath is an untunnelled
short-term central venous access catheter for renal replacement therapy.
A baby is admitted with severe diarrhoea and needs urgent resuscitation as his
consciousness level is deteriorating. The team is unable to find a vein to insert
an intravenous cannula.
D An intraosseous needle should be placed into the tibial medulla approximately
13 cm below the tibial tuberosity in the event of failure to gain intravenous
access during a paediatric resuscitation. It can be used for the administration of
drugs and fluids. The needle should be secured in place and fluids or drugs
syringed in with a 20-mL or 50-mL syringe. The main problem is dislodgement of
the needle and extravasation of fluid. Longer term complications include development of osteomyelitis.
Central venous access should be established to optimize filling pressures and allow
the administration of vasoactive drugs. Noradrenaline should be given through a
central line because of the risk of extravasation leading to tissue necrosis.
The anaesthetist would like intravenous access for the induction of anaesthesia
in a fit and well adult.
77 Pain relief
Answers: 1B, 2A, 3H, 4I
An 18-year-old man with a diagnosis of osteosarcoma has been admitted to
the cardiothoracic unit for removal of a metastasis in his right upper lung lobe.
He requires a thoracotomy.
B
Epidural analgesia improves morbidity in the high-risk patient and in major surgery such as a thoracotomy as the epidural infusion is usually based on a local
anaesthetic in combination with an opioid (fentanyl). The level of epidural analgesia is dependent on the dermatomal level needed to cover the surgical incision.
A 70-year-old day surgery patient needs analgesia prescribing following unilateral varicose vein surgery. The only past medical history of note is occasional
complaints of heartburn.
A Postoperative pain peaks initially and consequently eases. The analgesic ladder
(WHO) is used as a guide to treat acute postoperative pain. Pain may be assessed
using a verbal analogue score (VRS) to guide appropriate therapy: 0 no pain;
1 mild pain; 2 moderate pain; 3 severe pain; 4 worst pain. Different
operations are estimated to have different pain scores:
mild to moderate pain (e.g. varicose vein surgery, hysteroscopy)
moderate to severe pain (e.g. inguinal hernia repair, appendicectomy)
worst pain (e.g. thoracotomy, nephrectomy, laparotomy).
Balanced analgesia is a principle of pain management; i.e using non-opioid analgesics
such as paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) alongside
strong opioids. NSAIDs must be used with caution and may be contraindicated, for
example, in patients with renal impairment or gastrointestinal ulceration.
For severe and worst pain, invasive/parenteral analgesia is required and strong opioids can be administered via patient-controlled analgesia (PCA with morphine as
the drug of choice). PCA allows patients more control over delivery of analgesia
with the ability to deliver bolus injections. There may be a background infusion.
There is a limit to the size of the boluses and only a fixed preset amount of opiate
can be delivered over a period of time to prevent overdosage.
Ketamine is an NMDA antagonist and can be used as a induction agent but has
unpredictable onset and offset. Its use is restricted by its psychotropic side-effects
(dissociative anaesthesia).
Midazolam is one of the most frequently used benzodiazepines for sedation. Its
main actions are for hypnosis, sedation, anxiolysis and anterograde amnesia. The
action is linked to GABA receptors. It is short-acting due to its lipophilicity and
rapid rate of elimination. However it is not commonly used as an induction agent.
A 6-year-old girl scheduled for a tonsillectomy is severely needle-phobic. It is
felt that although an intravenous anaesthetic would be preferable, in this particular situation it would be too traumatic. After discussion with the mother
and child, the anaesthetist has offered the choice of a gas induction.
E
Gas induction refers to inducing anaesthesia by gases alone. This does not require
instant intravenous access. It is used in needle-phobic patients or in a situation
where the airway might be of particular concern. Historically it was the first route
to induce anaesthesia (Schimmelbusch mask).
Sevoflurane is a modern flurane vapour with advantages of rapid onset and offset,
with little irritation to the airway. Cyclopropane has been well tolerated but is
now obsolete (it is a flammable anaesthetic agent and its use is discouraged).
A 51-year-old woman is scheduled for a hysterectomy. The surgeons request
muscle relaxation. She has been nil by mouth for 10 hours and has no risk of
aspirating.
79 Oxygen therapy
Answers: 1C, 2G, 3F, 4H
A 20-year-old man was been knocked from his motorbike. He has a clear and
patent airway. Examination reveals a possible fractured pelvis and right femur.
C
This patient is likely to be hypovolaemic from loss of blood into his fractures. The
priority while he is being resuscitated is to maintain oxygen delivery to the tissues.
Tissue oxygenation depends on oxygen content of the blood, delivery and
consumption.
Oxygen content of the blood (millilitres of O2 per 100 mL of blood) is calculated
from: (Hb % Sat 1.36) (PO2 0.0031). In simple terms, this means that
Continuous positive airway pressure (CPAP) will supply positive airway pressure
throughout all phases of spontaneous ventilation. It is applied via a tight fitting
mask. CPAP will increase the functional residual capacity, thereby reducing airway
collapse and increasing arterial oxygenation. It is used in weaning from ventilation, chronic airway collapse and pulmonary oedema to improve oxygenation.
A 25-year-old woman is admitted to A&E with an acute exacerbation of her
asthma. Examination reveals wheeze throughout both lung fields.
H Nebulizers are devices to provide a suspension of droplets in a gas for administration of inhaled drugs or humidification. Droplets of 5 nm are deposited in the trachea and smaller ones in the alveoli. Ideal droplet size is 15 nm. In asthma,
nebulizers are used to enable bronchodilating drugs such as salbutamol (or in
severe cases adrenaline) to reach the bronchi.
80 Preoperative investigation
Answers: 1A, 2C, 3G, 4H
A 75-year-old man with a history of smoking 1015 cigarettes a day for
35 years is admitted for elective major surgery. He has a productive cough.
A This investigation is essential in any patient with significant history of respiratory
or cardiac disease or signs on clinical examination scheduled for major surgery. A
chest x-ray (CXR) is useful as an indication of structural abnormalities in these
conditions but shows less about function. A CXR is indicated as above unless there
is a film available within 612 months. Other indications include new/change in
symptoms, possible metastasis, or recent immigration from an area where tuberculosis is endemic. It also is a preoperative baseline for major surgery and some
anaesthetists request a CXR in all elderly patients.
A patient is scheduled for an anterior resection. He has COPD and complains
that he has had more chest tightness recently. You wish to assess his lung
function in the pre-assessment clinic.
C
Peak flow can be measured with a Wright spirometer as a simple bedside test for
obstructive lung disease. This can be indicative of the patients ability to cough
and expectorate secretions. The result is dependent on the patients weight, but
for a 70-kg male less than 200 mL/min indicates significant impairment. This test is
also to be repeated after bronchodilators have been administered to assess the
reversibility of the disease. Lung function tests are generally used to determine the
nature and extent of pulmonary disorders. Measurement of static lung volumes
are cumbersome. A spirometer is used to measure forced expiration and derived
variables. The ratio of FEV1/FVC is reduced in obstructive lung disease and normal
or high in restrictive lung disease. Flow volume loops will give the anaesthetist an
indication of the compliance of the lungs.
A 75-year-old woman attends the pre-assessment clinic prior to total hip replacement. She has had episodes of shortness of breath, chest pain and syncope.
This patient has the classical description of a leaking thoracic aortic aneurysm.
Treatment should be aimed at stabilization of his blood pressure while a definitive
diagnosis is made. He is hypertensive with a reasonable heart rate. Analgesia
should be given to treat his pain and also to lower his blood pressure. If this does
not control his blood pressure then a labetolol infusion would be a useful treatment option as it has both - and -adrenergic receptor blocking effects. GTN
acts as a venodilator and may not control his blood pressure effectively. It will also
not slow his heart rate. Once the patients blood pressure is controlled then cautious fluid challenges may be given to correct the poor urine output.
A 70-year-old diabetic Asian woman presents with intermittent central chest
pain. She is on a GTN, insulin and a heparin infusion in the cardiac unit.
Coronary angiogram shows severe triple-vessel disease. She is awaiting a coronary artery bypass graft but presents with further chest pain in the night.
Pulse 70/min, BP 90/50 mmHg, troponin T 0.05.
This woman has poor myocardial perfusion secondary to her coronary artery disease. If her myocardial oxygen demands increase she will be unable to increase
myocardial oxygen delivery and her myocardium will become more ischaemic and
contract poorly. This in turn worsens the situation. She needs her blood pressure
supported to maintain coronary perfusion without increasing myocardial oxygen
demand.
The intra-aortic counter-pulsation balloon pump is the ideal inotrope in patients
with a competent aortic valve. During diastole it inflates to increase coronary perfusion pressure and during systole it deflates reducing the afterload of the heart.
All chemical inotropes increase myocardial oxygen demand and are potentially
arrhythmogenic.
A 28-year-old male intravenous drug abuser is admitted to ITU with a red
inflamed mass in his groin. He is due to go to theatre to have the mass
explored. Heart rate is 115/min, BP 80/30 mmHg, and he is oliguric.
A 35-year-old man with septic shock is being treated in ITU. His mean arterial
blood pressure has dropped to 65 mmHg despite adequate fluid resuscitation.
B
SECTION 8: EMQS IN
PLASTIC SURGERY
82
83
84
Assessment of burns
Complications of burns
Skin cover
QUESTIONS
82 Assessment of burns
A
B
C
D
E
F
9 per cent
45 per cent
80 per cent
36 per cent
60 per cent
18 per cent
G
H
I
J
K
L
10 per cent
5 per cent
15 per cent
1 per cent
20 per cent
54 per cent
For each clinical scenario below choose the approximate percentage total burn
surface area. Each option may be used only once.
1
A 24-year-old man is rescued from a house fire and has suffered extensive partialthickness burns to the whole of his back and the posterior aspect of both legs.
A 16-year-old male suffers partial-thickness burns to the palm of his right hand.
An 8-year-old girl pulls a kettle of boiling water over herself, suffering fullthickness burns to her anterior trunk.
A 64-year-old engineer is involved in a major gas explosion, suffering fullthickness burns over the head and neck and partial-thickness burns to chest,
abdomen and arms.
83 Complications of burns
A
B
C
D
E
F
G
hypovolaemia
contractures
deep vein thrombosis
rhabdomyolysis
Curlings ulcer
type II respiratory failure
type I respiratory failure
For each clinical scenario below choose the most likely complication. Each option
may be used only once.
1
A 45-year-old woman is brought to A&E after being rescued from a house fire.
On examination she has suffered partial-thickness burns to both arms and fullthickness burns to her chest and the soles of her feet. She is distressed and coughs
up soot as she asks to see her family. Respiratory rate is 33 /min with poor chest
expansion. Pulse oximetry is 94 per cent (15 L O2 through non-rebreathe mask).
Auscultation of the chest reveals poor air entry bilaterally with no added sounds.
A 35-year-old man is being monitored on the burns unit after suffering fullthickness burns to his hands secondary to high-voltage electrocution. Urinalysis
reveals microscopic haematuria. Blood tests reveal a mild hyperkalaemia and a
creatinine kinase (CK) of 3000.
A 2-year-old child is brought to A&E acutely unwell by her mother 48 hours after
suffering a scald to the right forearm. On examination there is a flamazine
dressing over the burn site. The patient is pyrexial and tachycardic with a low
blood pressure.
A 47-year-old man with a full-thickness circumferential burn to the left arm complains of persistent pain refractory to morphine analgesia. On examination radial
and brachial pulses are palpable and the arm is too painful to examine.
84 Skin cover
A
B
C
D
E
F
G
H
For each clinical scenario below choose the most appropriate means of reconstruction. Each option may be used only once.
1
A 44-year-old woman would like breast reconstruction surgery following a rightsided mastectomy and postoperative radiotherapy. She is known to be a noninsulin-dependent diabetic and previously smoked 20 cigarettes a day.
A 25-year-old patient has suffered a full-thickness burn over the posterior aspect
of her trunk.
ANSWERS
82 Assessment of burns
Answers: 1D, 2J, 3F, 4B
The Wallace rule of nines is a simple and rough guide to assessing the extent of
burn injuries. The body is divided into 10 anatomical regions that are multiples of
9 per cent (see Figure 82.1). The perineum is estimated as 1 per cent, as is the
palmar surface of the hand, which is an alternative way of assessing percentage
body area involved. The most accurate method of assessing total body surface
area (TBSA) involved is the Lund and Browder chart which is used in burns units.
It is important to remember that the rule of nines needs to be modified when
applied to a child as the head represents a larger surface area and the legs represent a smaller surface area compared to an adult.
Although each case should be considered individually, it is suggested that burns
10 per cent of TBSA in adults and 5 per cent of TBSA in children should be
9
1
Flat of hand
18 + 18 = 36
9 + 9 = 18
9 + 9 = 18
Adult
referred to a burns centre. The other criteria for referral are: burns involving face,
hands, feet, genitalia, perineum, full-thickness burns 5 per cent, electrical and
chemical burns, burns with associated inhalation injury and circumferential burns
The TBSA affected is used to guide intravenous fluid resuscitation of the burns
patient. Resuscitation is started if burn involves 15 per cent of TBSA in adults
and 10 per cent of TBSA in children. There are a number of formulae that can
be used to estimate the fluid requirement.
Current ATLS guidelines suggest that 24 mL times bodyweight (kg) times per
cent TBSA should be administered in the first 24 hours. For example, a 70-kg
man with 20 per cent TBSA burns will require 28005600 mL in the first
24 hours. Half of this should be provided in the first 8 hours after the injury
and the remainder given in the final 16 hours.
The Muir and Barclay formula (preferred by UK burns units and using human
albumin solution) describes a formula for fluid resuscitation for the first
36 hours after burn injury: replacement volume (mL) 0.5 times bodyweight (kg) times per cent TBSA. This replacement volume should be given 4hourly for the first 12 hours, 6-hourly for the next 12 hours, and 12-hourly
for the final 12 hours.
It is important to recognize that all formulae are merely estimates and the
patients response to fluid (e.g. urine output) needs to be assessed continuously to
guide resuscitation.
83 Complications of burns
Answers: 1F, 2D, 3K, 4L
A 45-year-old woman is brought to A&E after being rescued from a house fire.
On examination she has suffered partial-thickness burns to both arms and
full-thickness burns to her chest and the soles of her feet. She is distressed
and coughs up soot as she asks to see her family. Respiratory rate is 33 /min
with poor chest expansion. Pulse oximetry is 94 per cent (15 L O2 through nonrebreathe mask). Auscultation of the chest reveals poor air entry bilaterally
with no added sounds.
F
the compliance of the chest wall causing respiratory embarrassment which results
in type II respiratory failure (i.e. ventilatory failure). An arterial blood gas may well
show hypercapnia due to reduced ability to expire CO2 that is consequently
retained. Urgent escharotomy is required to increase chest wall compliance.
Type I respiratory failure may also develop from carbon monoxide poisoning. It is
important to obtain an early baseline carboxyhaemoglobin reading and to persist
with maximal oxygen therapy. Arterial PO2 measurements do not reliably predict
carbon monoxide poisoning. Patients with serious burns are also at risk of developing type I respiratory failure from other mechanisms (e.g. pulmonary oedema
and acute lung injury).
A 35-year-old man is being monitored on the burns unit after suffering
full-thickness burns to his hands secondary to high-voltage electrocution.
Urinalysis reveals microscopic haematuria. Blood tests reveal a mild
hyperkalaemia and a creatinine kinase (CK) of 3000.
D Risk of development of rhabdomyolysis should always be considered in a patient
with electrocution injury. This is more likely with high-voltage (1000 V) than
domestic voltage injuries.
Rhabdomyolysis involves the breakdown of muscle fibres with the consequent
release of potentially toxic intracellular contents into plasma. The CK is characteristically raised several times above the reference range. There may be hyperkalaemia due to release from muscle. Urinalysis that is positive for blood but
negative for red blood cells implies myoglobinuria and is suggestive of
rhabdomyolysis. The urine has a characteristically dark appearance. Acute renal
failure may develop secondary to hypovolaemia and acute tubular necrosis
which is caused by toxic free radical products from myoglobin (these are formed
under acidic conditions). The myoglobin casts themselves may also cause tubular
obstruction.
Prompt treatment with intravenous fluid resuscitation and reversal of the acidosis
is crucial in treating impending renal failure.
A 2-year-old child is brought to A&E acutely unwell by her mother 48 hours
after suffering a scald to the right forearm. On examination there is a
flamazine dressing over the burn site. The patient is pyrexial and tachycardic
with a low blood pressure.
K
admission and treatment of children with minor burns who present acutely unwell
in the first few days following a burn injury.
A 47-year-old man with a full-thickness circumferential burn to the left arm
complains of persistent pain refractory to morphine analgesia. On examination
radial and brachial pulses are palpable and the arm is too painful to examine.
L
84 Skin cover
Answers: 1F, 2H, 3A, 4D
A 74-year-old woman presents to A&E with a small proximally based pretibial
laceration with no soft tissue loss. She is known to have ischaemic heart
disease, COPD and diabetes.
F
The skin over the tibia is susceptible to injury particularly in the elderly as the skin
is thin and inelastic with little subcutaneous soft tissue padding. Management can
be either conservative or surgical. Conservative closure with sterile adhesive strips
is preferred to suturing as they put the healing tissue under less tension and
sutures often tend to pull through. This is probably the best course of action in
the first instance in this scenario as the patient poses a significant anaesthetic
risk. Should the flap necrose then surgical management involves debridement of
devitalized tissue and split skin grafting.
A 44-year-old woman would like breast reconstruction surgery following a
right-sided mastectomy and postoperative radiotherapy. She is known to be a
non-insulin-dependent diabetic and previously smoked 20 cigarettes a day.
H There a number of options available for reconstruction of any area and there is a
huge range for the reconstruction of breasts. These can be carried out at the time
of mastectomy (i.e. immediate) or at a later date (i.e. delayed). The timing of surgery depends on the patients and surgeons preference.
Either a pedicled flap or a free flap may be used to reconstruct tissue defects. A
pedicled flap involves mobilizing tissue (muscle with skin and fat) on its blood
supply and siting into the new position without interrupting the blood supply. An
example of this with regard to breast reconstruction is a latissimus dorsi pedicled
flap. A free flap involves detaching the tissue (interrupting the blood supply),
reimplanting at the recipient site and performing a vascular anastomosis to the
local blood supply. An example of this with regard to breast reconstruction is the
TRAM (transverse rectus abdominis myocutaneous) free flap.
The type of reconstruction involves close discussion between surgeon and patient.
A free TRAM flap will give a superior cosmetic result and tends to have the better
blood supply, and in a patient with microvascular insufficiency (smoker, diabetic)
this would be the preferred option. Also the latissimus dorsi reconstruction often
requires an implant to achieve sufficient volume, which is at risk of becoming
infected given the patients diabetes.
A 25-year-old patient has suffered a full-thickness burn over the posterior
aspect of her trunk.
A A graft is a unit of tissue(s) that is transplanted to a new site independent of
blood supply. A split-thickness graft (STG) consists of the epidermis with a varying
amount of dermis, as opposed to a full-thickness graft (FTG) which contains the
entire thickness of dermis.
A split-thickness graft is useful for covering large areas due to larger donor areas.
An STG is harvested usually from the patients thigh using a dermatome. The donor
site then heals by re-epithelialization. The disadvantage of STG is that there is
increased contraction and poor cosmesis in comparison to a full-thickness graft.
The donor site of STG can also be slow to heal.
An FTG is useful for smaller areas where cosmesis is important and contraction
would be problematic (e.g. volar aspect of digits). They are less likely to take and
are limited in size as the secondary defect needs to be closed directly.
In the scenario given, a large area needs coverage and so a split-thickness graft is
the more practical option.
A 43-year-old woman presents with a biopsy-proven 3 cm 3 cm squamous
cell carcinoma over the right side of her forehead. Tumour excision included
the periosteum of the skull. The patient is particularly concerned about the
cosmetic outcome.
D In this case, primary closure of the defect will not be possible. An FTG will provide
a reasonable cosmetic result but will not take on bone (grafts require a vascularized bed to take, and the periosteum has been resected). The only reconstructive
option, which would also provide the best cosmetic outcome, would be a local
flap.
There are a number of possible designs for local skin flaps, which depend on the
site and size of the defect. In this case, bilateral advancement flaps may be used.
SECTION 9: DATA
INTERPRETATION
QUESTIONS IN SURGERY
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
QUESTIONS
85 Chest problem (i)
Fig. 85.1
pneumothorax
pleural effusion
left ventricular failure
haemothorax
tension pneumothorax
A 42-year-old man presents to A&E with marked shortness of breath. The likely
abnormality from this CXR is:
A
B
C
D
E
pneumothorax
pleural effusion
left ventricular failure
haemothorax
tension pneumothorax
87 Abdominal CT
Fig. 87.1
Crohns disease
ulcerative colitis
pseudomembranous colitis
diverticular disease
colorectal carcinoma
88 Perioperative problem
A 8
16
Fig. 88.1
A 54-year-old male is undergoing a laparoscopic cholecystectomy. While the surgeon is inflating the abdomen with gas the man develops a cardiac arrhythmia.
1
If those measures are not successful, what can be done if the patient is becoming
compromised from the arrhythmia?
89 CT colon
Fig. 89.1
diverticular disease
Crohns disease
ulcerative colitis
perforation of small bowel
carcinoma of colon
irritable bowel syndrome
colonic polyps
perforation of large bowel
90 Chest x-ray
Fig. 90.1
A 55-year-old man with a long history of epigastric and chest pain presents with
severe epigastric and abdominal pain. He has a history of ischaemic heart disease
and high blood pressure and is being treated by his GP for oesophageal reflux.
His pain is severe despite paracetamol, dihydrocodeine and 5 mg intramuscular
morphine. What is the most likely diagnosis?
A
B
C
D
E
F
G
H
I
unstable angina
gastritis
myocardial infarction
diaphragmatic hernia
acute gastric dilatation
perforated duodenal ulcer
severe reflux oesophagitis
pericardial effusion
acute pancreatitis
91 Skin lesion
A 32-year-old woman is referred to the dermatology clinic because she is concerned about the above 10-mm lesion on her lower shin. She is otherwise fit and
well, a non-smoker with no previous history of cancer. The lesion is occasionally
itchy but does not bleed. What is the most likely diagnosis?
A
B
C
D
E
F
G
H
keratoacanthoma
squamous cell carcinoma
basal cell carcinoma
dermoid cyst
malignant melanoma
benign naevus
papilloma
Kaposis sarcoma
92 Bowel problems
Case 1
A 42-year-old woman presents to A&E with a 2-day history of worsening abdominal pain and vomiting. Past medical history includes appendicectomy, gastritis
and irritable bowel syndrome. What does the x-ray suggest?
A
B
C
D
E
F
G
sigmoid volvulus
appendiceal abscess
small bowel obstruction
large bowel obstruction
uterine fibroids
familial adenomatous polyposis
intussusception
Case 2
A 75-year-old woman complains of persistent abdominal pain and distension
several days after a right hip procedure. What does the x-ray suggest?
A
B
C
D
E
F
G
H
93 Hand deformity
This man presents to his GP surgery complaining of roughness over the palm of
his hand and deformity of his little and ring fingers that has been worsening for
the last few years. What is your diagnosis?
A
B
C
D
E
flexor tenosynovitis
trigger finger
Dupuytrens contracture
ulnar nerve palsy
rheumatoid arthritis
94 Knee pain
Fig. 94.1
This 74-year-old woman presents with a 4-year history of severe pain in both
knees, worse on movement. She can barely walk to her bus stop 50 metres down
the road and has difficulty getting out of the bath. Examination is restricted due
to pain. She has mild pain in her hips but no other joints are affected. What does
the image suggest?
A
B
C
D
E
F
rheumatoid arthritis
osteoarthritis
psoriatic arthritis
SLE
osteoporotic fractures
septic arthritis
Plate 1 Colour image of Fig 86.1. A 42-year-old man presents to A&E with marked shortness of
breath. The likely abnormality from this CXR is? See Question 86, p 203.
Plate 2 Colour image of Fig 91.1. A 32-year-old woman is referred to the dermatology clinic because
she is concerned about the above 10-mm lesion on her lower shin. She is otherwise fit and well, a
non-smoker with no previous history of cancer. The lesion is occasionally itchy but does not bleed.
What is the most likely diagnosis? See Question 91, p 208.
Plate 3 Colour image of Fig 93.1. This man presents to his GP surgery complaining of roughness
over the palm of his hand and deformity of his little and ring fingers that has been worsening for the
last few years. What is your diagnosis? See Question 93, p 211.
Plate 4 Colour image of Fig 106.1. A 71-year-old woman presents for revision arthroplasty of the
right hip. Her mobility is restricted by her hip pain. She has no symptoms of cardiac or pulmonary
disease but on examination a harsh systolic murmur is heard. Transthoracic echocardiography
produces this image and reported data. See Question 106, p 225.
95 Hip x-ray
Fig. 95.1
This 84-year-old woman was found on the floor of her flat by the warden of her
residence. She was unable to stand and so was brought to A&E by ambulance.
She is otherwise fit and well. What is the most likely management option for this
patient?
A
B
C
D
E
F
96 Headache (i)
Fig. 96.1
This 35-year-old main presented with a severe headache that was unrelieved by
analgesia. He had been playing football but there was no obvious trauma identified by witnesses. In the A&E department his GCS drops suddenly, requiring
intubation and ventilation. What does the image sugest?
A
B
C
D
E
F
G
97 Headache (ii)
Fig. 97.1
An 80-year-old woman presents with worsening frontal headache and drowsiness. She is a poor historian and is unable to provide any medical history.
She denies any head injury. What does this image suggest?
A
B
C
D
E
F
98 Collapse
Fig. 98.1
This 46-year-old man was involved in an assault during which he suffered a blow
to the head. He was able to escape from his attackers but collapsed an hour later.
What does the image suggest?
A
B
C
D
E
F
99 Abdominal pain
Fig. 99.1
ovarian cyst
uncomplicated aortic dissection
hydatid cyst
ruptured aortic aneurysm
renal cell carcinoma
Fig. 100.1
Fig. 101.1
Fig. 102.1
MIBG scan
MAG3
bone scan
ultrasound scan
IVU
staghorn calculus
pelviureteric junction obstruction
obstructed right ureter
urethral stone
obstructed left ureter
104 Electrocardiogram
a F
Fig. 104.1
atrial flutter
sinus tachycardia
WolffParkinsonWhite syndrome
fast atrial fibrillation
sick sinus syndrome
A 71-year-old woman presents for revision arthroplasty of the right hip. Her
mobility is restricted by her hip pain. She has no symptoms of cardiac or pulmonary disease but on examination a harsh systolic murmur is heard.
Transthoracic echocardiography produces this image and reported data.
Aortic valve
Vmax 5 m/s
Maximum pressure gradient 100 mmHg
Ejection fraction
60 per cent
The clinical findings and echocardiogram result are consistent with a likely diagnosis of:
A VSD with bidirectional shunt
B mitral regurgitation
C aortic regurgitation
Answer: see page 243
D mitral stenosis
E aortic stenosis
107 Electrolytes
You are bleeped by nurses to review an 86-year-old woman who is reported to be
very confused. She was treated with a dynamic hip screw for a fractured neck of
femur 5 days ago. Her urea and electrolyte results are as below [with normal ranges]:
sodium 120 mmol/L [135145]
potassium 2.9 mmol/L [3.55.0]
creatinine 95 mol/L [60110]
urea 6.9 mmol/L [2.57.0].
What is the most likely cause for her deranged results?
A
B
C
D
E
PEFR (L/min)
FEV1 (L )
FVC (L)
FEV1/FVC (per cent)
Predicted [range]
Result
431 [367496]
2.65 [2.253.04]
3.72 [3.164.27]
68 [5878]
110
0.52
1.70
30
25
20
46
45
Which of the following diagnoses would correlate most with these lung function
tests?
A
B
C
D
E
lung fibrosis
pleural effusions
severe COPD
severe kyphoscoliosis
lung metastases
ANSWERS
85 Chest problem (i)
D haemothorax
The most obvious abnormality that can be seen is the presence of multiple rib
fractures and a right-sided haemothorax.
Key points
The presence of multiple rib fractures is concerning owing to the possible complication of flail chest. Flail chest occurs when a segment of the thoracic wall
becomes unattached from the rest of the chest wall. This most typically occurs
when ribs are fractured in two places, allowing that segment of the thoracic wall
to float independently of the rest of the chest wall. Clinically you may observe
paradoxical chest movements with respiration.
Management
Management of flail chest should follow the normal ABCDE prioritization as
delineated by the ALS/ATLS guidelines.
Pulmonary contusion, haemothorax and pneumothorax are the important complications to contend with when managing flail chest. The priorities are to provide
sufficient oxygenation of the lung, prevent further damage and allow pulmonary
toilet. The latter is particularly important in the elderly who are more susceptible
to developing pneumonia.
Maximal O2 therapy (high-flow oxygen with non-rebreathing bag).
Insertion of chest drain. Some advocate insertion of a prophylactic chest drain
due to the risk of pneumothorax/tension pneumothorax when delivering positive pressure ventilation to patients with multiple rib fractures.
Artificial ventilation. Positive pressure ventilation may be required if there is
severe chest wall instability resulting in inadequate spontaneous ventilation.
Intubation and ventilation is usually only required when there are pulmonary
contusions causing significant hypoxia. In these cases it is the underlying lung
injury that needs to resolve before weaning off ventilation rather than the
mechanical disruption to the chest wall.
Effective analgesia is vital to help prevent respiratory decompensation caused by
atelectasis and retained secretions. Opioid analgesia and posterior rib blocks can
be provided at an early stage. However, thoracic epidural anaesthesia is the gold
standard for delivering the analgesia essential for limiting complications and
speeding up recovery from flail chest.
tension pneumothorax
Key points
A tension pneumothorax occurs when the area of lung injury forms a valve
which allows air into the pleural cavity during inspiration but does not allow it to
leave during expiration. This generates high positive pressures pushing mediastinal contents to the contralateral hemithorax.
The classical signs include mediastinal shift (trachea deviated away from affected
side) with absent breath sounds on the affected side. Diagnosis can be difficult as
the patient is invariably in significant distress.
Management
If tension pneumothorax is suspected, immediate management involves the insertion of a cannula into the second intercostal space mid-clavicular line until a
functioning intercostal tube can be inserted. A chest x-ray should not be carried
out as it delays management of a life-threatening condition.
The British Thoracic Society have provided a simple algorithm for the management of spontaneous primary and secondary pneumothorax (secondary means
that there is underlying lung disease).
A small primary pneumothorax in an asymptomatic patient does not require
treatment.
A larger pneumothorax/symptomatic pneumothorax can be treated with aspiration. If unsuccessful, another attempt at aspiration may be made before
inserting an intercostal drain.
A small/asymptomatic secondary pneumothorax requires aspiration. If unsuccessful, one must proceed to intercostal drain insertion.
A large/symptomatic secondary pneumothorax should be treated with intercostal drain insertion.
87 Abdominal CT
D diverticular disease
The major abnormality that can be seen is diverticular disease/diverticulosis.
Pulsion diverticulae are herniations of the mucosa and submucosa of the entire
wall thickness through the muscularis. High intraluminal pressures and a weak
colonic wall at the sites of vessel penetration into the muscularis are believed to
be the underlying aetiological factors for herniation.
Key points
The sigmoid colon is the most affected site of diverticular disease. Risk factors
include age, a low-fibre diet and colonic motility disorders. Complications
include:
intestinal obstruction (large bowel)
diverticulitis
bleeding
abscess formation
perforation diverticula
fistulization.
Acute diverticulitis is defined as inflammation of a diverticulum. It is usually
caused by the build-up of stagnant faecal material in a diverticulum with obstruction of the neck of the diverticulum and mucus secretion/bacterial overgrowth.
Management
Management of acute diverticulitis includes:
ABCDE assessment
patient nil by mouth
intravenous access
FBC, U&Es, LFTs, amylase, CRP (pregnancy test if female)
blood cultures
abdominal x-ray
intravenous fluids plus broad-spectrum antibiotics
CT imaging if failure to improve.
Remember that this is a presentation of an acute abdomen and investigations
must be performed to rule out other causes for the patients presentation. Serum
C-reactive protein can be helpful for monitoring response to therapy/resolving of
diverticulitis. An abdominal x-ray is useful to identify any free air from perforation or intestinal obstruction.
Colonoscopy should be avoided in the acute situation due to risk of perforation.
CT imaging is useful to identify abscesses/fistulization if this is suspected or if the
patient fails to improve within 2448 hours. There is currently no evidence base
for any benefit conferred by routine CT imaging for all patients presenting with
diverticulitis.
88 Perioperative problem
This is bradycardia. Sinus bradycardia (in this case junctional rhythm) originates
from the sinoatrial node and is a common arrhythmia during anaesthesia in
healthy patients. In extreme cases it can lead to cardiac arrest.
89 CT colon
This contrast study shows the classical apple core lesion of colonic malignancy.
Key points
Genetic factors
90 Chest x-ray
F
This chest x-ray shows the presence of air under the diaphragm, and together
with the history of abdominal pain is suggestive of a perforated viscus. Air under
the diaphragm is easier to detect under the right hemidiaphragm as the gastric
bubble on the left side can make free air difficult to distinguish.
The differential diagnosis of air under the diaphragm includes (not an exhaustive list):
perforated viscus
iatrogenic (e.g. after abdominal surgery)
gas-forming infection
air per vaginum (e.g. abortion, gynaecological procedures, water-skiing)
pneumoperitoneum secondary to COPD.
91 Skin lesion
E
malignant melanoma
Tumour types
Prognostic factors
Clinical prognostic factors
Tumour thickness has been recognized as the most important prognostic factor in
melanoma patients with stage I and II disease. There are two described methods of
thickness measurement.
Clark level. This is based on the anatomical levels of involvement within the
cutaneous and subcutaneous structure, and five levels of invasion have been
described.
Breslow thickness. Tumour thickness in millimetres is the most reliable independent prognostic indicator in malignant melanoma. Additionally, it assists
in therapeutic decision-making with regard to the clearance margin for
tumours and indication for sentinel node biopsy.
92 Bowel problems
C Case 1: small bowel obstruction
F Case 2: large bowel obstruction
In small bowel obstruction, dilated loops of small bowel (3 cm diameter) are
usually seen centrally on an abdominal radiograph. Small bowel can be identified
by the presence of valvulae conniventes, mucosal folds that traverse the full
width of bowel. Erect films may reveal multiple fluid levels and absence of gas in
the large bowel, although this is not routinely performed.
Large bowel can be identified on an abdominal radiograph by the presence of
haustra, folds that partially cross the width of the bowel. Dilated loops are positioned peripherally. Other signs depend on the cause of obstruction (e.g. inverted
U from sigmoid volvulus).
Mechanical causes
Non-mechanical causes
Paralytic ileus.
Pseudo-obstruction.
Iatrogenic (e.g. anticholinergic, opiate medication).
Electrolyte abnormalities (e.g. hypokalaemia).
93 Hand deformity
C Dupuytrens contracture
This is a case of Dupuytrens contracture as characterized by nodular hypertrophy
and contracture of the palmar aponeurosis. The painless thickening classically
causes fixed flexion deformities of the little/ring finger at the MCP/PIP joints.
Key points
Most cases are idiopathic but other associations include alcohol, trauma, diabetes
and drugs (e.g. phenobarbitone). There is also an association with Peyronies disease, a condition characterized by fibrosis of the corpus cavernosum of the penis.
Treatment
Treatment involves surgery to dissect and excise the thickened part of the
aponeurosis.
94 Knee pain
B osteoarthritis
This woman gives a typical history of osteoarthritis pain.
Key points
Osteoarthritis is a degenerative joint disease primarily affecting cartilage over
weight-bearing joints (e.g. hips and knees in the elderly). It can occur in younger
age groups, particularly where there has been fracture into the joint.
The classical radiological signs of osteoarthritis are:
loss of joint space
osteophyte formation
subchondral cysts
subchondral sclerosis.
Management
Management may be conservative, medical or surgical. Conservative measures
include weight reduction and physiotherapy (particularly quadriceps strengthening). Medical treatment is analgesia provided via the analgesic ladder approach.
Definitive management, however, remains surgical with total knee replacement.
95 Hip x-ray
D hemiarthroplasty
This woman has a displaced fractured neck of femur (NOF; III/IV need a lateral
to confirm) and will require hemiarthroplasty (see below).
Key points
A fractured NOF can be broadly classified as being intracapsular or extracapsular.
The majority of the blood supply to the femoral head enters the capsule from
distal to proximal, so there is a high risk of disruption following intracapsular
fracture.
Garden classification
The Garden classification is the best known means of NOF classification (see
Figure 95.2):
Garden I: incomplete/impacted fracture (trabeculae of inferior neck are intact)
Garden II: complete fracture without displacement
Garden III: complete fracture with partial displacement
Garden IV: complete fracture with total displacement.
u a tal
an
al
nt a a ula f a tu
a
al
nt t o hant
u t o hant
t a a ula f a tu
Fig. 95.2 Reproduced with permission from Patel, K. 2006: Complete Revision
Notes for Medical Finals. London: Hodder Arnold.
Surgery
With a minimally displaced/undisplaced fractured NOF the blood supply is likely
to be intact and a dynamic hip screw or cannulated screws can be used for
fixation.
With a displaced fracture there is a high risk of blood supply disruption and consequently avascular necrosis of the femoral head. The femoral head must be sacrificed and replaced with a metal prosthesis (i.e. hemiarthroplasty).
96 Headache (i)
D subarachnoid haemorrhage
The CT shows subarachnoid haemorrhage (SAH) with intraventricular blood and
dilatation of the posterior horns of the lateral ventricles.
Classification
A useful clinical classification of SAH was described by Hunter and Hess in 1968:
grade 1: asymptomatic or minimal headache; slight nuchal rigidity
grade 2: moderate to severe headache; nuchal rigidity; no neurological deficit
except cranial nerve palsy
grade 3: drowsy; mild neurological deficit
grade 4: stuporous; moderate to severe hemiparesis; may have early decerebrate rigidity
grade 5: deep coma; decerebrate rigidity.
Key points
In a young patient without a history of trauma, SAH is likely to be secondary to
rupture of a cerebral aneurysm or arteriovenous malformation.
The classical history is of the thunder-clap headache. The patient may describe
the sensation of being kicked in the back of the head. A full neurological examination must also include looking for signs of meningism. The diagnosis is usually
confirmed by CT, and cerebral angiography allows the causative lesion to be more
readily identified.
Management
Patients should ideally be looked after in a neurosurgical or high-dependency setting as they require close monitoring and may deteriorate rapidly. Acute complications include the development of hydrocephalus which may require insertion of
an extraventricular duct to reduce intracranial pressure. Electrolytes should be
closely monitored as a hyponatraemia secondary to SIADH may develop.
Vasospasm may worsen cerebral ischaemia, and regular oral nimodipine is often
used to reduce the complication rate from vasospasm. Seizures should be treated
and the patient may need a phenytoin infusion.
97 Headache (ii)
E
Key points
Subdural haemorrhage may be acute or chronic. Fresh blood appears white
(hyperdense) on a CT scan and implies acute pathology. A subdural haematoma is
classically crescentic in shape and concave to the skull.
It is important to remember that subdural haemorrhage can occur after relatively
minor trauma in high-risk patients (e.g. the elderly, alcoholics). This is believed to
be due to brain atrophy increasing the tension within bridging veins that makes
them more susceptible to shearing forces.
Signs
Clinically the patient may have obvious localizing neurology or simply an altered
level of consciousness. Signs to look out for are a hemiparesis contralateral to the
side of haematoma, and eye signs (e.g. dilated non-reactive ipsilateral pupil or
papilloedema secondary to increased intracranial pressure).
Management
Most subdural haematomas that are small, causing no midline shift or neurological signs, can be managed conservatively with serial scans and neuro-observations to rule out further bleeding/haematoma progression.
Large haematomas causing midline shift require a craniotomy for surgical evacuation of clot and haemostasis which allows decompression of the brain.
Chronic subdural haematomas can usually be managed conservatively with serial
scans and neuro-observations. Many of these patients do not report any history
of trauma and so diagnosis may be difficult.
If the haematoma is significant and requires evacuation, this can be carried out
via burr holes. If the haematoma is non-liquefied then a craniotomy will be necessary as adequate decompression will not be possible via burr holes.
98 Collapse
D extradural haemorrhage
The CT scan shows a white (hyperdense) convex-shaped lesion (described as
lentiform as it looks like a lens). This is a collection of blood between dura and
skull (i.e. extradural haemorrhage).
Key points
Extradural haemorrhage is typically caused by trauma, especially to the side of
the head where fractures over the temporal/parietal bone can cause rupture of the
middle meningeal artery.
The classical description is of a head injury with/without consciousness followed
by a lucid interval and then subsequent deterioration in consciousness that is
associated with increasing intracranial pressure. As the bleeding is arterial the
haematoma can expand quickly with rapid deterioration.
Management
An extradural haemorrhage is a neurosurgical emergency. If it is not treated
promptly there is a risk of cerebral herniation and brainstem compression leading
to death. The treatment of choice is by burr hole/craniotomy to evacuate the
haematoma. Any bleeding vessels may be ligated for haemostasis.
99 Abdominal pain
D ruptured aortic aneurysm
The image is a contrast-enhanced spiral CT scan of the abdomen, showing a ruptured aortic aneurysm. The central anatomical structure is an enlarged aorta
immediately anterior to the centrum of a lumbar vertebra. The aneurysm is partially filled with thrombus with an eccentric contrast-filled lumen. Contrast is also
seen in the thrombus. The calcified aortic wall is clearly depicted with a breach in
the right posterior aspect in continuity with blurred tissue planes created by
extravasation and consistent with a rupture.
Key points
Abdominal aortic aneurysm (AAA) is defined as a segmental dilatation of all
layers of the vessel wall resulting in a 50 per cent or more increase in the vessel
diameter.
The incidence of AAA is on the increase in western societies. Risk factors for
developing AAA include age, male gender, smoking, hypertension, chronic
obstructive pulmonary disease and family history.
Management
Reliable intravenous access should be established with two large-bore catheters
and bloods sent for FBC, U&Es, cross-matching (at least six units) and clotting
screen. The vascular surgical team should be contacted immediately.
The decision to perform further imaging in a case of suspected rupture is critical.
In a haemodynamically stable patient, contrast CT scan of the abdomen and
pelvis is useful both for confirmation of the diagnosis if in doubt and for the
planning of appropriate treatment. An unstable patient should be taken to theatre
as soon as possible for laparotomy and emergency repair. Endovascular repair is
an option in selected cases.
Surgery is vital to resuscitation in this scenario. Systolic pressure should be maintained at about 90 mmHg until proximal control is achieved. Aggressive preoperative fluid resuscitation to maintain normal pressure is often detrimental to
outcome.
Key points
Carotid artery stenosis is the most common cause of stroke (which is the third
commonest cause of death in western societies, after myocardial infarction and
cancer).
Atherosclerosis is common at the carotid bifurcation, often extending into the
origin of the internal carotid artery. The risk of stroke is related to the degree of
stenosis, previous stroke and recent transient ischaemic attack (TIA). The risk of
stroke is highest soon after a TIA: 5 per cent during the first month following the
TIA and 2025 per cent within 2 years.
Management
Medical management includes smoking cessation, antiplatelet therapy
(aspirin/clopidogrel), cholesterol lowering, control of diabetes and hypertension,
and exercise.
Two large trials (NASCET and ECST) have long established the superiority of surgery over medical therapy alone in symptomatic severe stenosis. In asymptomatic
patients, surgery is beneficial only in the presence of low perioperative complications and over a 5-year period (ACAS and ACST trials).
Presentation
The presence of established collaterals suggests that this is a longstanding occlusion and therefore likely to present as a chronic claudication rather than acute
ischaemia. The distal left superficial femoral artery is occluded with popliteal
reconstitution.
The superficial femoral artery mainly supplies the leg and foot. The thigh is supplied by the profunda femoral artery given off at or just below the groin by the
Management
Exercise, especially walking, is beneficial in claudicants. Studies have unequivocally demonstrated that participation in a standardized exercise programme
improves the pain-free walking distance or time of claudicants.
The image shows a short-segment occlusion and the patient may benefit from
conservative management in the first instance with optimum cardiovascular risk
management and exercise. If unsuccessful, the lesion should be amenable to balloon angioplasty. Surgery should be considered only in worsening claudicants
where the above options are contraindicated or unsuccessful.
Key points
The control film does not show an identifiable cause for the obstruction. The
complete series reveals obstruction in the lower third of the left ureter. The right
side is the unobstructed side and shows a healthy peristaltic urethra. Note that
sometimes contrast may pass rapidly through an unobstructed system such that
you may not see any excretion from the healthy urinary tract. A staghorn calculus is identifiable on KUB. An obstructed urethra would reflect on both kidneys.
Key points
When assessing IVU films always look first at the control film and ensure that the
entire urinary tract is imaged from kidneys to urethra. Identify any opacification
in the path of the ureter that may resemble an obstructing calculus.
Intravenous contrast is injected and an immediate film is taken next which should
show a nephrogram (i.e. contrast taken up by the kidney) which will give an idea
of size and outline of each kidney.
Several films are taken at intervals showing passage of contrast through the collecting system, ureters and bladder, and eventually a post-micturition film is
taken. If there is delayed excretion on one side, this can indicate obstruction. It is
therefore useful for detecting anatomical abnormalities such as stones, tumours
and obstruction.
In some departments, IVU is being replaced by CT urogram.
104 Electrocardiogram
D fast atrial fibrillation
The scale of this ECG is 10 mm/mV. The rate can be estimated by the simple equation 300 divided by the number of large squares between two rs. This can be difficult to calculate in an irregular rhythm such as atrial fibrillation. However, an
estimated rate can be given as a range: in this case around 140150 beats/min.
Key points
Atrial fibrillation is one of the most commonly observed arrhythmias during
anaesthesia.
The atrial contraction approximately makes a 25 per cent contribution to the cardiac output, so fast atrial fibrillation can cause a significant reduction in blood
pressure particularly if there is pre-existing cardiac failure.
Treatment
The treatment for this condition depends on the cardiovascular instability.
Immediate cardioversion is indicated if a clinically significant reduction in cardiac output is present.
If there is time, an echocardiogram should be performed to exclude any thrombi
before converting to sinus rhythm. Anticoagulation should be initiated with heparin.
Electrolyte imbalances should be corrected, particularly potassium and magnesium.
Adequate fluid resuscitation is important to preserve preload and cardiac output.
Once precipitating factors have been addressed, drugs for long-term chemical cardioversion and/or rate control may be considered.
Key points
After minor surgery, warfarin may usually be started on the first postoperative
day. Reinstating warfarin following major surgery depends on the nature of the
procedure and any coexisting factors (e.g. in-situ epidural analgesia).
Vitamin K reverses the action of warfarin within 6 hours, but recommencing anticoagulation can be difficult and has to be advised by the haematologist.
Epidural analgesia is contraindicated with impaired coagulation due to the
increased risk of epidural haematoma. An epidural haematoma can lead to spinal
cord compression which is a medical emergency. An urgent MRI scan is required
if neurological symptoms are present and surgical intervention may be necessary.
An INR below 1.5 and a platelet count above 80 000 is required for an epidural
catheter to be safely inserted or spinal injections to be given.
Low-molecular-weight heparin should be stopped 12 hours pre-insertion.
aortic stenosis
This is a transthoracic apical view of the heart revealing severe aortic stenosis
with a peak gradient of 100 mmHg. Severe aortic stenosis leads to progressive left
ventricular hypertrophy which may be seen on an ECG. The patient is at high risk
of developing cardiovascular complications during the procedure. Although this
patient is in a great deal of pain and needs to have her operation as soon as possible, it is a non-emergency procedure and the aortic stenosis is amenable to
treatment. There is a clear case for postponing surgery to allow optimization of
the patient by the cardiology/cardiothoracic teams.
Key points
Shortness of breath, chest pain and syncope are the classic three symptoms to
watch out for in aortic stenosis. As each symptom appears, the patients prognosis
worsens.
A patient with aortic stenosis symptomatic with angina has a life expectancy of
around 5 years. Angina plus syncope reduces this to 3 years, and the presence of
the whole complement of angina plus syncope plus dyspnoea is associated with a
life expectancy of less than 2 years.
107 Electrolytes
A intravenous fluid such as 5 per cent dextrose
This patient is suffering from hyponatraemia and hypokalaemia.
Hyponatraemia
Hyponatraemia is a relatively common finding in hospital patients. It may occur
as a result of water retention or sodium loss. Therefore it may be associated with
an expanded, normal or contracted extracellular fluid volume. In diagnosing the
cause one needs to evaluate the extracellular fluid volume status; i.e. whether
hypovolaemia (renal loss, extrarenal loss), hypervolaemia (congestive heart failure, cirrhosis) or normovolaemia (SIADH, drugs, stress) is present.
Acute hyponatraemia is a medical emergency. It may be treated promptly using
hypertonic saline, for example. Hyponatraemia is associated with confusion, convulsions and ultimately death.
If the hyponatraemia appears to be of a more chronic onset, then it needs to be
corrected slowly as rapid correction can result in pulmonary oedema or even
acute pontine demyelination.
Hypokalaemia
Hypokalaemia is defined as a potassium level less than 3.5 mmol/L. Non-specific
symptoms can include nausea and anorexia, muscle weakness and paralytic ileus.
Cardiac arrhythmias and cardiac arrest are possible, so it is important to monitor
the ECG and give supplementary potassium either orally or in i.v. fluids, not more
than 0.5 mmol/kg hourly. Central venous access is required if a potassium infusion needs to be administered. Correction of potassium deficiency should also be
accompanied by magnesium correction if at all possible.
values for flows and volumes. Normal values for forced expiratory volume (FEV)
and forced vital capacity (FVC) are based on population studies and vary according to race, height, age and gender.
Ranges
Values for FVC and FEV1 (forced expiratory volume in 1 second) that are over
80 per cent of predicted are defined as within the normal range.
The FEV1/FVC ratio is expressed as a percentage, and a normal young individual
is able to forcibly expire at least 80 per cent of his/her vital capacity in 1 second.
A ratio under 70 per cent suggests underlying obstructive physiology as there is a
significant drop in forced expiratory volume compared with forced vital capacity.
In a restrictive lung defect (e.g. pulmonary fibrosis) the FEV1/FVC ratio may be
normal or even increased as both FEV1 and FVC are decreased.
Flow/volume curve
Obstructive lung disease also changes the appearance of the flow/volume curve.
As with a normal curve, there is a rapid peak expiratory flow, but the curve
descends more quickly than normal and takes on a concave shape. With more
severe disease, the peak becomes sharper and the expiratory flow rate drops precipitously. This results from dynamic airway collapse which occurs as diseased
conducting airways are more readily compressed during forced expiratory efforts.
Indications
Lung function tests are indicated preoperatively to assess the extent of the
patients functional impairment. This can be predictive of perioperative outcome
regarding postoperative ventilation. Patients with severe obstructive lung disease
need preoperative optimization with bronchodilators, physiotherapy and exclusion of any infection.
In the appropriate clinical setting, one may consider a trial of bronchoprovocative
testing with bronchodilators to exclude asthma.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Abdominal pain
Weight loss
Hepatobiliary surgery
Signs of chronic liver disease
Paediatic surgery
Surgical radiology
Inflammatory bowel disease
Skin lesions
Thyroid malignancy
Thyroid disease
Urology investigations
Renal calculi
Lump in the groin
Dizziness/vertigo
Sore throat
Dysphagia
Neck lumps
The paediatric hip
Upper limb nerve injury
Lower limb nerve injury
21
22
23
24
25
26
27
28
29
30
31
32
33
34
10
Abdominal pain
Box 1 lists the classical abdominal pain descriptions that come up in EMQs.
Box 1 Abdominal pain descriptions
Description
Problem
Ureteric colic
Biliary colic
Acute pancreatitis
Acute appendicitis
Ectopic pregnancy
Perforated viscus
Weight loss
As shown in Box 2, weight loss is a classical soft sign towards malignancy in
an EMQ.
Box 2 Some associations between weight loss and malignancy
Symptoms
Malignancy
Oesophageal carcinoma
Bronchial carcinoma
Bladder carcinoma
Sigmoid/rectal carcinoma
Carcinoid syndrome
Hepatobiliary surgery
The two conditions in Box 3 are frequently confused with each other and commonly
crop up in EMQs.
Box 3 Primary biliary cirrhosis and primary sclerosing cholangitis
Presentation
Condition
Primary sclerosing
cholangitis
-1 antitrypsin deficiency
Pigmentation, diabetes
Haemochromatosis
Wilsons disease
KayserFleischer ring
Paediatric surgery
Look out for the features in Box 5 in EMQS concerning paediatric surgical
presentations.
Box 5 Paediatric signs
Condition
Feature
Pyloric stenosis
Projectile vomiting
Right upper quadrant mass
Intussusception
Hirschsprungs disease
Duodenal atresia
Bilious vomiting
Double bubble on x-ray
Surgical radiology
Box 6 shows phrases to look out for describing x-ray features in EMQs.
Box 6 X-ray features
X-ray feature
Condition
Sentinel loop
Acute pancreatitis
Inverted U loop
Sigmoid volvulus
Ulcerative colitis
Cobblestoning
Crohns disease
Apple-core lesion
Carcinoma of colon
Crohns disease
Skip lesions
Weight loss, diarrhoea, abdominal pain
Strictures, anal fistulae
Barium enema:
cobblestoning, rose-thorn ulcers
Granulomas
Only affects colon
Continuous disease
Diarrhoea with blood and mucus
Fever, tachycardia, toxic megacolon in
severe acute UC
Barium enema:
Loss of haustra
Sigmoidoscopy:
Oedematous, friable mucosa
No granulomas
Ulcerative colitis
Skin lesions
Look out for particular phrases in questions describing skin lesions. The descriptive features in Box 8 direct you to the likely diagnosis.
Box 8 Characteristic skin lesions
Skin lesion
EMQ feature
Sebaceous cyst
Punctum
Keratoacanthoma
Ganglion
Neurofibroma
Lipoma
Keloid
Melanoma
Thyroid malignancy
Box 9 lists features to look out for in questions concerning thyroid malignancy.
Box 9 Features of thyroid cancer
Thyroid cancer
Features
Follicular carcinoma
Papillary carcinoma
Anaplastic carcinoma
Usually elderly
Aggressive, so may be rapidly growing mass,
airway compression
Medullary carcinoma
Lymphoma
Thyroid disease
Box 10 lists features to look out for in questions concerning thyroid dysfunction.
Box 10 Thyroid dysfunction
Thyroid condition
EMQ features
Hashimotos thyroiditis
Graves disease
Endemic goitre
De Quervains thyroiditis
Urology investigations
Box 11 lists common investigations that come up in EMQs.
Box 11 Urology investigations
Investigation
Uses
USS
Cystourethroscopy
Intravenous pyelography
Positive-pressure urethrogram
MRI
Renal calculi
Box 12 lists the incidences and associations of renal calculi.
Box 12 Renal calculi
Calculus
Incidence
Calcium oxalate
75 per cent
Associations
Alkaline urine
Disordered calcium metabolism
(e.g. hyperparathyroidism
Increased oxalate absorption
(e.g. Crohns disease)
Triple phosphate
15 per cent
Alkaline urine
Urea splitting organisms
(e.g. Proteus)
Urate
5 per cent
Cysteine
2 per cent
Yes
No
Yes
Inguinal hernia
Yes
Yes
No
Cough impulse
Cord lipoma
Yes
Yes
No
Painless
Epididymal cyst
Yes
Yes
Yes
Varicocoele
Variable
Yes
No
Bag of worms
Dizziness/vertigo 261
Dizziness/vertigo
Box 14 gives clues about assessing a patient presenting with dizziness.
Box 14 Testing for dizziness/vertigo
Diagnosis
Duration
Tinnitus
Loss of hearing
Precipitant factors
BPPV
Seconds
None
None
Specific head
movements
Menires disease
Hours
Unilateral
Unilateral
None
Vestibular neuronitis
Days
None
None
None
Acoustic neuroma
Varies
Unilateral,
persistent
Gradual
unilateral
reduction
None
Sore throat
Sore throat has a number of causes, but Box 15 identifies the findings for various
conditions.
Box 15 Some causes of sore throat
Diagnosis General
Speech Trismus
malaise and
temperature
Appearance
Quinsy
Yes
Hot
potato
Yes
qWCC,
neutrophilia
Tonsillitis
Yes
Normal
No
Bilateral tonsil
swelling
erythema
spotty white
exudate
qWCC,
neutrophilia
Glandular
fever
Yes
Normal
No
Bilateral tonsil
Massive
swelling white nodes
membranous
exudate
Acid reflux No
Normal
No
Normal
oropharynx
Normal
Normal
Tonsil
carcinoma
Normal
No
Unilateral tonsil
swelling/
ulceration
Nodal
mets may
be present
May be raised
WCC
No
Neck
Enlarged
nodes
Bloods
qWCC,
lymphocytosis
Paul Bunnell
test positive
qLFTs
Dysphagia
Dysphagia has a number of causes, but Box 16 identifies the findings for various conditions.
Box 16 Some causes of dysphagia
Diagnosis
True
dysphagia
Regurgitation
of food
Neck
swelling
Referred
otalgia
Other
features
Pharyngeal
pouch
Yes, progressive as
pouch enlarges
Yes, typically
after minutes
and undigested
Yes, if large
No
Globus
pharyngeus
No
No
No
No
Hypopharyngeal
carcinoma
Yes, gradually
progressive from
solids to liquids
If large may be
regurgitation
Yes, from
metastatic nodes
Thyroid goitre
Yes, if large
No
Antero-inferior,
moves on swallowing
No
Oesophageal
achalasia
Yes
No
No
Diffuse oesophageal
spasm
Yes
No
No
No
Bulbar palsy
Yes
No
No
No
Neck lumps
Box 17 identifies lumps that are likely to be implicated in EMQs.
Box 17 Some cause of neck lumps
Diagnosis
Site
Thyroid
swelling
Midline lower
neck
Yes
No
Bruit on auscultation
Signs of thyrotoxicosis
(e.g. atrial fibrillation,
tremor, eye signs)
Thyroglossal
cyst
Typically midline
region of hyoid,
may be just lateral
to midline
Yes
Yes
Branchial cyst
No
Transilluminates
May present in later life
with infection
Position often characteristic
in question
Chemodectoma
Lateral neck,
bifurcation of
carotid
No
No
Submandibular
Below ramus
mandible
No
No
Bimanually palpable
Stone may be palpable in
submandibular duct
Marginal mandibular nerve
palsy in malignant cases
Parotid
Parotid region,
but can occur at
angle of mandible
No
No
Cystic hygroma
Posterior triangle
No
No
Condition
Features
Perthes disease
Usually male
Hip pain and limp (311 years)
X-ray: decreased size femoral head, patchy
density
Often obese
Older than Perthes patient (1016 years)
Groin pain, limp
Flexed, abducted, externally rotated hip
Nerve implicated
Features
Median nerve
Ulnar nerve
Radial nerve
Axillary nerve
Winged scapula
Nerve implicated
Features
Tibial nerve
Sciatic nerve
Reflex/movement
Nerve root
Supinator
C5, C6
Biceps
C5, C6
Triceps
C7
Knee
L3, L4
Ankle
S1
Shoulder abduction
C5
Elbow flexion
C5, C6
Elbow extension
C7
Finger abduction
T1
Hip flexion
L1, L2
Hip extension
L5, S1
Knee flexion
L5, S1
Knee extension
L3, L4
Ankle dorsiflexion
L4, L5
S1
Clinical signs
Diagnosis
Dupuytrens contracture
Colles fracture
De Quervains syndrome
Clinical signs
Diagnosis
Meniscal tear
OsgoodSchlatters disease
Plantar fasciitis
Ewings sarcoma
Osteosarcoma
Red eye
The many causes of red eye are summarized in Box 24.
Box 24 Interpreting red eye
Clinical signs
Diagnosis
Hazy cornea
Pupil fixed and dilated
Raised intraocular pressure
Blurred vision, photophobia
Anterior uveitis
Inflammatory cells
May be autoimmune disease
Vision normal, injected conjunctiva
Bacterial conjunctivitis
Viral conjunctivitis
Allergic conjunctivitis
Corneal ulceration
Endophthalmitis
Retinal signs
Retinal signs are listed in Box 25.
Box 25 Interpreting retinal signs
Clinical signs
Diagnosis
Hypertensive retinopathy
Diabetic retinopathy
Glaucoma
Papilloedema
Retinitis pigmentosa
Cataract
CMV retinitis
Pupils 273
Pupils
Pupilar signs are listed in Box 26.
Box 26 Interpreting pupilar signs
Clinical signs
Diagnosis
Brainstem death
Amphetamines, cocaine
Plus euphoric
Opiate overdose
Pontine haemorrhage
Dilated pupil
Ptosis, down-and-out pupil
Neurosyphilis
Horners syndrome
Ocular movements
Ocular signs are listed in Box 27.
Box 27 Interpreting ocular movements
Lesion
Ocular movement
Cranial nerve IV
Cranial nerve VI
Failure to abduct
Horizontal diplopia worse on abduction
Clinical finding
Diagnosis
Bitemporal hemianopia
Superior quadrantanopia
Inferior quadrantanopia
Homonymous hemianopia
Central scotoma
Macula (degeneration/oedema)
Hypertensive retinopathy
Hypertensive retinopathy is given a grading (see Box 29).
Box 29 Grading of hypertensive retinopathy
Grading
Features
Silver wiring
II
AV nipping
III
IV
Diabetic retinopathy
Retinopathy in diabetes is staged (see Box 30).
Box 30 Stages of diabetic retinopathy
Stage
Features
Background
Maculopathy
Pre-proliferative
Proliferative
Pre-proliferative neovascularization of
disc/retina
Neurosurgery/head injury
Some features of head injury likely to come up in EMQs are listed in Box 31.
Box 31 Features of head injury or pathology
Features
Subdural haemorrhage
History of trauma
Particularly elderly/alcoholic in EMQ
C T: white crescentic lesion concave to skull
Extradural haemorrhage
Anosmia, rhinorrhea
Periorbital bruising (racoon eyes)
Bruising behind ear/haemotympanum
Subarachnoid haemorrhage
Imbalance
pH
PCO2
HCO
3
ABE
Respiratory acidosis
Partially compensated
Fully compensated
Respiratory alkalosis
pp
Partially compensated
pp
pp
Fully compensated
Metabolic acidosis
pp
pp
Partially compensated
pp
Fully compensated
Metabolic alkalosis
Partially compensated
Fully compensated
N, normal
Condition
Features
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
Use
Type
Secondary intention
Primary intention
Flap (local/pedicled/free)
Index
284 Index
aneurysm (Continued)
cerebral 236, 237
false 312
femoral 110, 123
surgical repair 32, 96, 100, 101
thoracic aortic 190
true 31
angina 2434
angiography 95, 99, 219, 2401
angioplasty 95, 97, 100, 102, 241
anhydrosis 152, 161
ankle brachial pressure index 95, 99
ankylosing spondylitis 72, 88
anorexia 4, 31, 143
antacids 131, 139, 142
anterior cruciate ligament tear 71, 87, 270
anterior resection 7, 356
anterior uveitis 271
anti-thyroglobulin antibodies 51
anti-thyroid peroxidase antibodies 51
antibiotics 30, 33, 115, 1389, 1446
broad-spectrum 42, 88
intravenous 54, 144, 165
anticholinergic agents 120, 231
anticoagulation 224, 2423
antihistamines 140
antiplatelet agents 97, 102
aortic aneurysm 94, 96, 98100, 190,
217, 2389, 248
aortic arch 218, 239
aortic dissection 99
aortic stenosis 225, 2434
aortobiiliac repair, open 94, 98
aortofemoral bypass 95, 100
aponeurosis 234
appendicectomy 4, 31, 172, 176, 181, 186
appendicitis 34, 29, 31, 176, 186, 248
appetite loss 104, 11314
apple core lesion 206, 231, 253
arch supports 89
arrhythmia 171, 180, 205, 2301
arterial blood gases 171, 1801, 27980
arterial stenosis 218, 23940
arteriosclerosis 167
arteriovenous malformation 236
artery of Adamkiewicz injury 96, 101
arthritis 63, 789, 89
lumbar spinal/hip 94, 98
mutilans 79
psoriatic 79
rheumatoid 11, 39, 63, 72, 789, 88
septic 64, 80
seronegative 79
tuberculous 65, 80
see also osteoarthritis
arthrodesis 89, 90
ascending cholangitis 14, 42
ascites 11, 40
aspiration 229
aspirin 79, 99
assault 27, 59, 76, 92, 216, 238
asthma 130, 13940, 171, 177, 181, 188
asystole 171, 180
atherosclerosis 102, 123, 239, 240
ATLS guidelines 197
atracurium 187
atrial fibrillation 95, 100, 223, 242
atropine 231
autoimmune diseases 51, 164, 165
autosomal dominant conditions 40, 114,
159, 168, 169, 183, 231
autosomal recessive conditions 162
axillary lymph node dissection 16, 46
axillary nerve 75, 86, 91, 266
axonal injury, diffuse 27, 60, 278
back pain 66, 72, 823, 88, 94, 989, 107,
11920
backslab 68, 845
barium 13, 42, 1423
Barlows test 81
basal cell carcinoma 12, 17, 41, 46, 255
Battles sign 60
Becks triad 56
benign paroxysmal positional vertigo
(BPPV) 128, 136, 261
benign prostatic hypertrophy 106,
11718, 118
biceps, long head 70, 86, 269
biliary cirrhosis, primary 250
biliary obstruction 42
biliary tree, air in the 43
bladder
cancer 104, 108, 111, 113, 121, 1245
imaging 2202, 2412
outflow obstruction 106, 108, 11618,
121
volume studies 117
Index 285
gauges 184
large-bore 174, 1834, 185
carbon dioxide, end tidal trace 173, 183
carbon monoxide poisoning 198
carcinoid syndrome 249
cardiac disease 189, 195, 199
cardiac murmur 225
cardiac output 180
cardiac tamponade 24, 56
cardiopulmonary arrest 179, 191
carotid artery stenosis 97, 1012, 218,
23940
carotid endarterectomy 25, 57, 97, 102
carpal tunnel 75, 91, 269
carpopedal spasm 180
cataract 151, 161, 272
catheterization 117, 118, 239
cellulitis 95, 99
central retinal artery occlusion 272
central retinal vein occlusion 157, 166,
272
central venous line 174, 185
central venous pressure 23, 54
cerebral contusion 27, 59
cervical rib 135, 147
Charcots triad 42
chemodectoma 135, 147, 264
chemoradiotherapy 116
chemosis 156, 165
chemotherapy 16, 46, 113, 148, 174, 184
chest
drain 55, 56, 228
flail 24, 55, 228
pain 67, 78, 83, 171, 17880, 18990,
2434
trauma 234, 536
see also x-ray, chest
chiasma lesion 275
Chlamydia 115
choking 134, 146
cholangitis, primary sclerosing 250
cholecystectomy, laparoscopic 205,
2301
cholecystitis 2, 23, 28, 43, 54, 112, 126
cholesteatoma 128, 137
chondrocalcinosis 64, 80
choroidal naevi 159, 169
circulatory overload 26, 58
circumcision 116, 172, 182
286 Index
Index 287
exophthalmos 20, 51
extracorporeal shock wave lithotripsy
(ESWL) 122
eye
care 145
discharge 150, 160
inherited disease 159, 1689
signs 25, 51, 567, 237
eyelid 1556, 166
furrows 155, 164
lump 159, 169
swelling 150, 156, 160, 165
failure to thrive 151, 161
falls 27, 59, 65, 67, 69, 81, 846
family screening 119
fasciotomy 83, 96, 101
fatigue 21, 51, 66, 82, 155, 164
feeding 2, 22, 523
Feltys syndrome 11, 39
femoral artery 95, 100, 219, 2401
femoral epiphysis, slipped 65, 80, 265
femoral head 65, 81, 236
femoral hernia 124
fentanyl 173, 183, 185
fibreoptics 172, 182
fibroadenomata 15, 44
fibroids 5, 323
finger 62, 77
Finkelsteins sign 62, 77
fissure-in-ano 6, 33
fistula 22, 52, 137
aortoenteric 94, 989
carotid-cavernous 156, 166
fistula-in-ano 6, 33
fistulogram 33
fixed performance mask, 28 per cent 177,
188
flap 281
free 195, 199200
local 195, 200
pedicled 199200
flashing lights 157, 159, 167, 168
flatus tube 41
flexion 57, 623, 74, 778, 901, 211,
234
floaters 152, 157, 159, 162, 1678
flow/volume curve 2445
flucloxacillin 45, 88
288 Index
Index 289
haemophilia 64, 79
Haemophilus influenzae 144, 145, 165
haemorrhage
extradural 216, 238, 278
pontine 273
retinal 157, 1667
subarachnoid 25, 57, 214, 2367, 278
subdural 27, 59, 215, 237, 278
haemorrhoidectomy 34
haemorrhoids 6, 34
haemothorax 24, 56, 202, 228
haemotympanum 60
Hallpike Dix manoeuvre 136
hallux rigidus 73, 89
hand 62, 67, 778, 83
claw 75, 91
deformity 211, 234
falls on outstretched 69, 856
lump 18, 48
pain 67, 83
Hartmanns procedure 7, 35, 94, 98
Hartmanns solution 22, 53
Hashimotos disease 21, 51, 257
haustra 233, 253
HCO
3 171, 1801, 279
head injury 22, 27, 53, 5960, 216, 238,
278
headache 26, 58, 128, 137, 150, 1523,
160, 1623, 21415, 2367
cluster 155, 164
frontal 158, 168, 215, 237
thunder-clap 236
Heberdens nodes 78
Helicobacter pylori 29
hemianopia 153, 163, 275
hemiarthroplasty 74, 90, 213, 2356
hemicolectomy 4, 7, 31, 35
hemithyroidectomy 131, 142
heparin 224, 242, 2423
hepatobiliary surgery 250
hepatosplenomegaly 11, 40, 135, 138,
148, 151, 161
hernia 31, 124, 22930
incarcerated (irreducible) 30
inguinal 110, 123, 124, 260
strangulated 4, 30
herpes zoster oticus 133, 1445
hesitancy 106, 107, 117, 118
Hickman line 174, 184
hip
congenital dislocation 65, 81, 265
hemiarthroplasty 74, 90
irritable 65, 81
pain 65, 801
x-ray 213, 2356
Hirschsprings disease 10, 38, 252
HIV 112, 126
Horners syndrome 155, 164, 273
central 162, 165
ipsilateral 91
postganglionic 162, 165
preganglionic 152, 1612, 165
tests 1612
house dust mites 140
human papillomavirus (HPV) 6, 34,
1456
hunger 10, 38
hydrocephalus 236
hydrocoele 105, 115, 260
hydrotherapy 88
hyoid bone 147
hypercalcaemia 113, 126
hypercarbia 180
hypercoagulative states 40
hyperkalaemia 194, 198
hyperplasia 19, 49
hypertensive retinopathy 157, 1667,
272, 276
hyperthermia, malignant 173, 183
hyperthyroidism 51, 155, 164
hypertrophy 19, 50
hyperuricaemia 79
hyperventilation syndrome 180
hypervolaemia 226
hypocalcaemia 180
hypokalaemia 226
hyponatraemia 226
hypopharyngeal carcinoma 132, 143, 263
hypothyroidism 51
hypovolaemia 23, 534, 226
hypoxia 55, 177, 180, 188
hysterectomy 32, 106, 11617
ileal conduit formation 111, 125
ileal pouch 8, 36
ileostomy 8, 36
iliac fossa 35, 29, 302
immunosupression 126
290 Index
Index 291
292 Index
Index 293
294 Index
Index 295
296 Index
Index 297
in newborns 10, 39
and vertigo 128, 137
Wallace rule of nines 196
warfarin 224, 2423
wart
genital 146
perianal 6, 34
weight gain 21, 51
weight-bearing 68, 84
wheeze 177, 188
white cell count 112, 126
Wilsons disease 151, 161, 251
wrist conditions 62, 67, 69, 77, 845
wrist drop 76, 92